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RD546  M95  Operative  surgery  of 

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Murphy 


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Operative  surgery  of  the  gall  tracts. 


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OPERATIVE  SURGERY  OF  THE  GALL 

TRACTS, 

With  Original  Report  oi'   Twkntv  Succios^kiji.  Ciiomccystkntfr- 

OSTOMIES    BY    MeANS    Ol'      THE   AnASTOMUSIS    Jiu-|"IOi\. 


JOHN  B.    MURPHY,    M.   D.,    Chicago,    III. 

I^KOFESSOK    OF    SURCxERY,    COLLEGE    OF    PHYSICIANS    AND  SURGEONS  ;    PROFESSOR  OF    SURfrEKY, 

POST-GKAUUATE  MEDICAL  SCHOOL  AND  HOSPITAL  ;   ATTENDING  SURGEON  COOK   COUNTY 

HOSPITAL  ;    ATTENDING  SURGEON  ALEXIAN    BROTHERS  HOSPITAL  : 

VICE  PRESIDENT  OP  NATIONAL  ASSOCIATION   OF 

RAILWAY  SURGEONS,   ETC. 


A\-i7i/  /'c'/orc'  the  Section  on  Siirp;<;ry  and  Anatomy  at  the  Forly-fourt]i  Annual  Mectii 
of  the  Ainen'ean  Medical  .  Issociation . 


Kepri)iled  from  The  Chicago  Medical   Recorder,   March,   iSq4. 


PRESS    OF 

The  McGluer  Printing  Company 
63  dearborn  st.,  chicago. 


OPERATIVE  SURGERY  OF  THE  GALL  TRACTS, 

With  Original  Report  of  Twenty   Successful  Cholecystenter- 

OSTOMIES    BY   MeANS  OF   THE  ANASTOMOSIS    BUTTON. 
By  JOHN  B.   MURPHY,   M.  D.,   Chicago,   III. 


PHOFESSOR  OF    SURGERY,    COLLEGrE    OF     PHYSICIANS    AMD     SURGEONS;     PROFESSOR  OF  SURGERY j, 

POST-GRADUATE  MEDICAL  SCHOOL  AND  HOSPITAL;  ATTENDING  SURGEON  COOK  COUNTY 

HOSPITAL;   ATTENDING  SURGEON  ALEXIAN  BROTHERS  HOSPITAL; 

VICE  PRESIDENT  OF  NATIONAL  ASSOCIATION  OF 

RAILWAY  SURGEONS,  ETC. 


Of  the  many  absorbing  topics  of  medical  literature,  of  the 
many  changes  in  the  art  of  surgical  treatment  made  in  the  last  two 
decades,  of  the  many  glorious  achievements  attained  in  this  period 
under  aseptic  and  antiseptic  methods,  of  the  many  of  these  iri 
which  the  results  are  still  imperfect  and  offer  great  reward  for  hon- 
est experimental  and  clinical  research,  one  of  the  youngest  and  yet 
a  very  interesting  and  inviting  one  is  the  surgery  of  the  gall  tracts. 
All  of  its  achievements  are  the  fruit  of  very  little  over  a  decade  of 
labor,  and  probably  we  have  only  just  begun  to  make  progress  in  this 
direction;  great  possibilities  are  before  us.  In  drawing  your  atten- 
tion to  this  subject  to-day,  it  is  not  my  desire  so  much  to  enumer- 
ate the  steps  already  accomplished,  as  it  is  to  ask  your  assistance 
for  its  further  advancement.  The  scope  of  this  paper  includes 
only  the  operative  element  of  the  surger}'-  of  the  gall  tracts;  I  will 
therefore  not  go  into  details  as  to  the  lesions  which  produce  the 
necessity  for  the  operation,  but  will  only  refer  to  them  cursorily,  as 
indications  for  the  special  operations  to  be  performed.  We  will 
First  devote  a  few  minutes  to   the   surgical  anatomy  of  the  region 

Read  before  the  Section  on  Surgery  and  Anatomy  at  the  Forty-fourth  An- 
nual Meeting  of  the  American  Medical  Association. 


in  which  they  are  situated,  as  well  as  to  the  tracts  themselves. 
Second,  we  will  consider  the  functions  or  physiology  of  the  gall 
bladder  and  gall  tracts;  for  good  surgery  is  based  on  good  physi- 
ological principles,  and  good  operations  must  be  executed  on  good 
anatomical  lines.  Third,  we  will  take  up  the  individual  operations, 
and  the  special  indications  for  each. 

THE    GALL    BLADDER. 

The  fundus  of  this  organ  lies  opposite  the  ninth  costal  cartil- 
-age,  close  to  the  outer  edge  of  the  rectus,  the  body  itself  is  situated 
in  a  fossa  on  the  under  surface  of  the  right  lobe  of  the  liver,  having 
the  quadrate  lobe  to  its  left.  It  is  in  immediate  contact  with  the 
hepatic  flexure  of  the  colon,  and  the  first  portion  of  the  duodenum. 
The  gall  bladder  is  of  pyriform  outline,  and  when  full  is  seen  pro- 
jecting beyond  the  anterior  border  of  the  liver,  coming  in  contact 
with  the  abdominal  wall  at  the  cartilage  of  the  ninth  rib.  It  ex- 
tends almost  directly  backward,  deviating  only  a  little  to  the  right 
and  upward;  it  measures  from  two  and  one-half  to  four  inches  in 
length,  and  one  and  one-half  inches  in  diameter  at  the  widest  part, 
and  holds  about  one  fluidounce.  It  is  always  found  full,  except  where 
some  external  pressure  is  brought  to  bear  upon  it.  It  is  attached  to 
the  liver  by  connective  tissue,  the  lower  surface  is  covered  by 
peritoneum,  though  occasionally  it  entirely  surrounds  the  viscus 
and  forms  a  sort  of  mesentery  to  attach  it  to  the  liver.  The  neck 
of  the  gall  bladder  gradually  contracts  until  it  forms  the  cystic 
duct.  This  duct  is  a  tube  an  inch  to  an  inch  and  a  half  long, 
which  connects  the  neck  of  the  gall  bladder  with  the  hepatic  duct, 
and  combines  to  form  the  common  duct,  or  the  ductus  communis 
choledochus.  The  cystic  duct  is  directed  backward  and  to  the 
left  as  it  runs  in  the  lesser  omentum;  the  hepatic  artery  being  to 
the  left  and  the  portal  vein  behind.  The  hepatic  artery  passes 
behind  the  hepatic  duct  and  between  it  and  the  portal  vein.  This 
is  a  very  important  point  to  remember,  as  it  assists  the  operator 
in  differentiating  between  the  duct  and  the  vein  in  operations. 
The  duct  and  the  vein  having  the  same  color,  and  being  situated 
in  close  proximity,  it  is  very  important  to  recogize  the  duct  in  this 
situation  above  the  artery,  and  the  vein  below  it.  The  hepatic 
duct  is  formed  by  a  branch  from  each  lobe  of  the  liver  in  the  trans- 
verse fissure,  and  is  directed  downward  and  to  the  rilght  in  the  les- 
ser omentum,  the  hepatic  artery  being  to  the  left  at  its  first  part, 
and  then  behind.  It  is  not  quite  two  inches  long  and  joins  with 
t"he  cystic  duct  to  form  the  common  duct.     The  common  bile  duct 


is  about  three  inches  in  length,  it  passes  down  between  the  layers 
of  the  lesser  omentum,  immediately  in  front  of  the  portal  vein,  and 
to  the  right  of  the  hepatic  artery;  it  then  passes  behind  the  first 
part  of  the  duodenum,  then  between  the  second  part  and  the  head 
of  the  pancreas  and  ends  at  the  lower  part  of  the  second  segment 
of  the  deodenum  by  opening  into  that  part  of  the  intestine  on  its 
left  side  and  somewhat  behind.  It  pierces  the  intestinal  wall 
very  obliquely,  running  between  the  muscular  layers  for  about 
three-quarters  of  an  inch.  The  pancreatic  duct  enters  the  common 
duct  just  before  its  termination.  Immediately  below  where  the 
pancreatic  duct  opens  into  the  common  duct,  there  is  a  dilatation 
of  the  common  tube,  called  the  ampulla  of  Vater.  There  is  a  slight 
constriction  at  the  terminus  of  the  duct,  the  papilla.  This  papilla 
in  the  duodenum  is  about  four  inches  from  the  pylorus.  The  com- 
mon duct  has  a  diameter  of  two  lines,  its  width  at  the  ampulla  is 
three  lines,  it  is  narrowest  at  its  outlet  into  the  duodenum.  The 
cystic  and  hepatic  ducts  are  a  little  narrower  than  the  common 
duct.  The  diameter  of  the  ducts  is  a  matter  of  considerable  prac- 
tical importance;  that  of  the  cysticus  and  choledochus  being  so 
near  alike,  that  a  concrement  that  will  produce  obstruction  in  the 
former  will  do  the  same  in  the  latter,  though  of  a  lesser  degree  un- 
til it  reaches  the  ampulla,  where  there  is  considerable  more  space. 
Stones  are  frequently  retained  in  the  ampulla,  as  the  orifice  of  the 
duct  in  the  intestine  is  much  smaller  than  any  portion  of  the  tract. 
Calculi  retained  in  this  position  buried  behind  the  duodenum  pro- 
duce very  grave  symptoms,  as  jaundice,  and  a  septic  fever  of  a 
typical  intermittent  character.^ 

Obstruction  at  this  point,  on  account  of  its  location,  is  so  very 
difficult  to  reach  and  remove  that  the  surgeon,  in  place  of  attack- 
ing the  obstacle  producing  the  obstruction,  selects  a  method  of 
circumventing  it  and  allows  the  bile  to  enter  the  duodeum  through 
another  tract,  viz.,  by  cholecystenterostomy.  It  will  be  seen  that 
the  distance  from  the  fundus, of  the  gall  bladder  to  the  opening  of 
the  duct  in  the  duodenum  is  made  up  of  the  combined  lengths  of 
the  gall  bladder,  ductus  cysticus  and  choledochus,  measuring  in 
all  from  six  and  a  half  to  eight  and  a  half  inches.  This  should  be 
remembered  in  sounding  the  ducts  for  obstructions  with  a  bougie 
or  probe.  The  gall  bladder  consists  of  three  coats,  the  serous,  the 
fibrous  and  muscular,  and  mucous.  The  serous  coat  covers  only 
about  two-fifths  of   the  surface,  that   on   its  under  side.     The  mu- 

'  See  Dr.  W.  E.  Quine's  excellent  monograph  on  this  subject. 


cous  is  raised  in  rugae,  bounding  polygonal  spaces,  which  are 
largest  about  the  body.  These  rugae  play  an  important  part  in  the 
formation  of  hepatic  calculi.  The  mucous  membrane  is  lined  with 
columnar  epithelium,  and  contains  many  mucous  glands.  At  the 
neck  the  mucous  membrane  forms  folds  projecting  into  the  interi- 
or acting  as  valves,  Heister's.  This  layer  contains  an  anastomosis 
of  blood  vessels  and  a  fine  plexus  of  lymphatics;  the  presence  of 
these  lymphatics  accounts  for  the  formation  of  secondary  abscesses 
and  septic  manifestations  from  infective  lesions  of  the  gall  bladder. 
The  fibrous  and  muscular  coat  consists  more  of  fibrous  than  mus- 
cular tissue  and  has  but  very  little  power  of  contraction,  since  I 
found  in  the  healthy  gall  bladder  of  the  dog,  by  ligating  the  ductus 
cysticus,  that  only  a  small  quantity  of  bile,  average  thirty  drops, 
was  forced  out  by  the  automatic  contraction  of  the  gall  bladder 
through  a  canula  placed  in  its  wall;  this  quantity  representing 
only  about  six  per  cent  of  the  contents  of  the  gall  bladder. 

PHYSIOLOGY. 

This  leads  us  to  a  consideration  of  the  physiology  of  the  gall 
bladder.  The  gall  bladder  is  credited  by  physiologists  with  being 
the  store  house  for  the  bile.  Landois  states  that  "the  gall  is 
secreted  continually,  but  part  is  stored  in  the  gall  bladder,  and 
poured  out  copiously  during  digestion."  This  expresses  the  ac- 
cepted theory  of  the  functions  of  the  gall  bladder.  I  desire  to 
question  the  correctness  of  this  theory,  and  in  order  to  place  the  is- 
sue more  clearly  before  you,  I  make  the  assertions,  bold  as  the}' 
may  seem,  first,  that  the  gall  bladder  is  not  for  the  purpose  of  storing 
the  bile  and  delivering  it  into  the  intestines  on  demand;  second, 
that  the  gall  bladder  is  the  controller  or  governor  of  the  tension  of 
the  bile  circulation.  When  we  consider  that  the  amount  of  bile 
secreted  daily  is  forty  ounces,  Murchison;  566  grams,  Westphalen; 
or  652  cubic  centimeters,  John  Ranke;  or  about  105  minims  to 
each  pound  of  body  weight,  we  can  readily  see  what  little  differ- 
ence it  would  make  in  the  quantity  and  current  of  bile  entering  the 
intestines  at  the  time  of  digestion,  even  if  the  gall  bladder  should 
contract  and  empty  its  whole  contents,  one  ounce,  into  the  intes- 
tine during  the  period  of  two  hours  of  time,  /.  e,  the  two  hours  be- 
tween three  and  five  hours  after  the  ingestion  of  a  meal.  For  in- 
stance, the  bile  flows  most  rapidly  at  two  periods  viz.,  between 
three  and  five  hours  and  between  eleven  and  thirteen  hours  after 
the  ingestion  of  food;  in  those  two  periods  about  ten  ounces  of  bile 
is  discharged.     If    the  quantity  of  bile  forced  out  of  the  gall  blad- 


der  by  its  inherent  contraction,  one-half  drachm,  be  added  or 
taken  from  these  ten  ounces,  would  it  make  any  perceptible  differ- 
ence in  the  current?  It  can  be  readily  seen  that  it  would  make  no 
appreciable  difference  in  the  whole  quantity  discharged,  i.  e.,  ten 
ounces.  We  are  then  forced  to  the  conclusion  that  the  liver  se- 
cretes at  these  periods  this  large  quantity  and  that  it  is  not 
"poured  out"  by  the  gall  bladder  as  stated  by  Landois.  Again,  if 
the  function  of  the  gallbladder  were  to  contract  and  expel  its  con- 
tents during  the  act  of  digestion,  would  we  not  frequently  find  an 
empty  and  physiologically  contracted  gall  bladder  either  ante-mor- 
tem or  post-mortem  ?  I  have  yet  to  find  one,  notwithstanding  I  have 
observed  them  on  the  living  and  dead  subjects,  at  all  hours  before 
and  after  eating  and  I  have  yet  to  see  a  surgeon  who  has  found  a 
physiologically  empty  gall  bladder.  That  the  gall  bladder  does  not 
empty  and  fill  with  each  digestive  act  is  further  supported  by  the 
fact  that  the  bile  in  the  healthy  gall  bladder  is  of  much  greater 
specific  gravity  than  that  in  the  hepatic,  cystic  and  common  ducts 
of  the  same  subject.  The  bile  in  the  cystic  duct  is  like  the  bile  in 
the  hepatic  and  common  ducts,  and  differs  from  that  in  the  fundus 
of  the  gall  bladder.  If  the  bile  in  the  gall  bladder  emptied  and 
filled  several  times  in  each  twenty-four  hours,  i.  e.,  after  each  meal, 
it  should  have  the  same  specific  gravity  as  the  bile  in  the  cystic 
duct,  which  is  not  the  case.  Further,  the  bile  in  the  cystic  duct, 
has  the  same  specific  gravity  as  that  in  the  hepatic  and  common 
ducts  which  shows  that  only  this  small  quantity  changes  with  the 
contraction  and  dilatation  of  the  gall  bladder.  This  degree  of  con- 
traction and  expansion  is  very  limited,  depending  on  the  degree  of 
tension  of  the  bile  circulation.  After  ligation  of  the  cystic  duct  at 
its  junction  with  the  gall  bladder,  and  extirpation  of  the  latter,  it 
has  been  found  that  in  a  number  of  months  the  cystic  duct  be- 
comes much  dilated,  resembling  a  miniature  gall  bladder,  Oddi.  I 
have  verified  this  by  one  experiment. 

Experiment  III. — Dog,  male,  weight  thirty-five  pounds.  May 
14,  1892,  cholecystectomy,  silkworm  gut  ligature  of  adhesions  to 
liver;  subsequent  section,  silkworm  gut  ligature  of  ductus  cysticus, 
top  sewing  peritoneum.  The  dog  was  sick  for  the  first  forty-eight 
hours,  after  that  he  rapidly  improved  and  in  four  days  he  was  ap- 
parently as  well  as  ever.  No  jaundice.  June  12,  the  dog  has  be- 
come very  fat  and  is  the  most  playful  dog  in  the  laboratory.  August 
31,  dog  killed.  The  cystic  duct  was  found  to  be  dilated  to  a  glob- 
ular sac,  five-eighths  of  an  inch  in  diameter. 

After  a  gall  bladder  and  intestinal  fistula  has  been  established, 


gradual  contraction  occurs;  the  gall  bladder  contracts  to  a  tube  not 
much  larger- than  the  cystic  duct,  as  the  element  of  tension  is  here 
entirely  removed.  This  change  requires  several  weeks.  I  do  not 
know  that  dilatation  of  the  cystic  duct  after  cholecj'^stectomy  has 
been  observed  in  man;  it  is  possible  that  it  does  not  occur  since  in 
man  there  is  no  sphincter  muscle  at  the  opening  of  the  common 
duct  into  the  intestine,  as  in  the  dog.  The  tension  theory  of  the 
gall  bladder  is  further  supported  by  the  mechanical  relations  of 
the  gall  bladder  and  cystic  duct  to  the  hepatic  and  common  ducts. 
It  will  be  noticed  that  they  occupy  the  same  relative  position  to 
the  current  of  bile  passing  along  the  hapatic  and  the  common  ducts 
that  the  air  chamber  in  the  fire  engine  does  to  the  stream  of  water 
flowing  from  the  pump  to  the  hose.  The  elasticity  of  air  in  the 
small  air  chamber  contributes  greatly  toward  producing  a  con- 
tinuous instead  of  a  pulsating  stream,  as  would  occur  with  the 
strokes  of  the  piston,  were  there  no  elastic  chamber.  In  place  of 
the  air  in  the  case  of  the  gall  bladder  we  have  the  elasticity  of  the 
walls  of  the  viscus  itself,  which  keeps  up  the  continuous  pressure 
by  its  expansion  and  contraction  and  thus  acts  as  a  tension  con- 
troller of  the  bile  circulation.  The  gall  bladder  is  congenitally 
absent  in  a  considerable  number  of  animals  and  men,  and  its  ab- 
sence appears  to  have  no  appreciable  effect  on  the  health  of  the 
organism.  I  have  gone  into  the  details  of  this  somewhat  thoroughly 
because  a  clear  understanding  of  the  physiological  principles  is 
necessary  in  order  that  we  may  better  judge  the  most  desirable 
operations  to  be  performed  under  given  circumstances. 

The  various  pathological  conditions  of  the  gall  tracts  which 
necessitate  operative  interference  requiring  laparotomy,  to  which 
line  of  operations  this  paper  will  be  confined,  I  will  only  mention 
by  name,  and  will  not  go  into  the  details  of  each.  In  the  order  of 
frequency  with  which  they  produce  disturbances  they  should  be 
classified  as  follows: 

1.  Cholelithiasis,  gall  stones;  a,  in  the  gall  bladder;  b,  in  the 
ductus  choledochus;  c,  in  the  ductus  cysticus;  d,  in  the  ductus 
hepaticus;  e,  in  the  diverticula;  f,  ulcerative  perforation  into  the 
peritoneal  cavity. 

2.  Cholecystitis,  empyema,  hydrops. 

3.  Cancer  of  the  pancreas, 

4.  Neoplasms  involving  the  ducts. 

5.  Carcinoma  of  the  gall  bladder. 

6.  Traumatism. 


OPERATIONS. 

The  operations  on  the  gall  tracts  after  the  abdomen  has  been 
opened  are  well  divided  into  ten  classes,  viz.: 

1.  Puncture  of  the  gall  bladder. 

2.  Incision  into  the  gall  bladder  without  further  operative 
procedure. 

3.  Suture  of  the  gall  bladder  to  the  abdominal  wall  with 
secondary  incision,  cholecystostomy,  two  sittings. 

4.  Suture  of  the  gall  bladder  in  the  abdominal  wall  with  im- 
mediate incision,  cholecystostomy,  one  sitting. 

5.  Incision  of  the  gall  bladder,  removing  its  contents,  im- 
mediate suture  of  the  gall  bladder  and  suturing  it  in  the  wound 
of  the  abdomen,  cholecystotomy. 

6.  Incision  of  the  gall  bladder  with  immediate  suture  and 
reposition  in  the  abdomen,  cholecystendysis,  ideal  cholecystot- 
om5^ 

1.      Cholecystenterostomy,  gall  bladder  and   intestinal  fistula. 

8.  Cholecystectomy.  Removal  or  apiputation  of  the  gall 
bladder. 

9.  Choledocholithotripsy  or  crushing  of  gall  stones  in  chole- 
dochus. 

10.  Choledocholithectomy,  with    subsequent    suture   of  duct. 

INDIVIDUAL    OPERATIONS. 

I.  Puncture  of  tJie  Gall  Bladder. — The  puncture  of  nonadherent 
gall  bladder  after  opening  the  abdomen  has  been  performed  but  a 
very  limited  number  of  times  (twenty-five),  and  through  error  in 
diagnosis  in  the  greater  number  of  cases.  Eight  times  the  opera- 
tion was  performed  for  its  therapeutic  effect,  after  the  abdomen  had 
been  opened.  Four  of  these  eight  were  supposed  to  be  circum- 
scribed hydrops  of  the  peritoneum;  two  of  these  cases  terminated 
fatally.  In  the  other  four,  the  diagonis  was  clear  and  the  object 
of  treatment  was  to  relieve  the  patient  by  aspirating  the  gall  blad- 
der. The  cause  of  the  dilatation  was  in  three,  cancer  of  the  pan- 
creas; in  one  it  was  due  to  calculus  in  the  cystic  duct.  The  final 
outcome  in  one  case  was  unknown;  one  of  the  cases  died  of  ex- 
haustion after  repeated  puncture;  in  the  other  two  cases  cholecystot- 
omy was  performed,  one  of  two  died.  We  have  here  then  a  fatality 
of  twenty-five  per  cent  from  simple  puncture  of  the  nonadherent 
gall  bladder.  In  the  other  seventeen  cases  the  puncture  was  purely 
explorative.  Puncture  of  the  gall  bladder  from  the  surface  of  the 
abdomen  without  incision  was  suggested  by  G.  Harley  for  the  pur- 


pose  of  sounding  for  gall'stones.  He  pronounced  it  an  easy  and 
safe  method  for  sounding  for  impacted  stones,  but  his  patient  died 
twenty-four  hours  after  the  operation  of  "enteritis  and  peritonitis." 
This  operation  is  to  be  condemned  first,  because  there  is  great 
doubt  that  a  diagnosis  can  be  made  with  a  needle,  even  if  a  stone 
is  present.  Second,  a  needle  puncture  of  the  gall  bladder  is  danger- 
ous because  the  opening  remains  patulous,  as  I  have  frequently 
«een  following  aspiration  preparatory  to  insertion  of  the  button, 
from  an  absence  or  very  limited  contractile  power  of  the  tissues  of 
the  wall  of  the  gall  bladder  and  from  tension  by  the  bile  pressure 
within.  Third,  if  the  contents  of  the  gall  bladder  in  the  case  should 
be  septic,  we  would  have   as  a  result   a    septic   peritonitis.      Cour- 


FiGURE  1. — Drainage  tube  button  illustrating  half  of  button  threaded  for  intro- 
duction into  gall  bladder. 

voisier  says,  "that  a  surgeon  should  even  hesitate  to  aspirate  a  case 
where  the  diagnosis  of  gall  bladder  lesions  was  even  suspicious, 
and  never  except  where  no  other  means  of  diagnosis  is  left,  a  lap- 
arotomy being  a  much  more  rational  and  safe  method." 

II.  Incision  of  the  Gall  Bladder  Without  Further  Operative  Pro- 
icedure. — This  operation  is  performed  for  and  should  be  limited  to 
cases  where  the  gall  bladder,  on  account  of  the  gangrene  of  its 
wall  or  extensive  adhensions  all  around  it  render  it  impossible  to 
either  suture  it  to  the  abdominal  wall  or  approximate  it  to  any  por- 
tion of  the  intestinal  tract,  and  where  it  is  compulsory  to  secure 
drainage  of  the  bladder  or  to  use  the  bladder  as  a  canal  to  allow 
the  escape  of  bile  in  obstructive  jaundice,  that  jeopardizes  the  life 
of  the  patient.  A  drainage  tube  may  be  inserted  in  the  incision  of 
the  gall  bladder  and  packed  around  with  gauze  (Maurice  H.  Rich- 
ardson), the  omentum  drawn  about  it  with  a  few  sutures  to  prevent 
the  fluid  passing  into  the  peritoneal  cavity,  or  what  is  still  better, 


my  method  of  insertion  of  a  "button  tube  drainage,"  of  the  pattern  I 
here  present,  Fig.  1.  This  has  the  advantage;  (1,)  that  it  can  be 
easily  and  rapidly  inserted  deep  in  the  abdominal  cavity,  though  the 
gall  bladder  may  be  very  much  contracted;  (2,)  that  it  prevents  with 
certainty  the  contact  of  the  gall  bladder  contents  with  the  abdominal 
viscera  until  such  time  as  adhesions  have  formed  around  the  tube; 
and  3,  that  it  leaves  a  large  opening,when  the  instumentis  withdrawn 
from  the  gall  bladder,  through  which  calculi  may  be  extracted. 
The  operation  with  the  "button  tube"  is  performed  as  follows:  An 
incision  is  made  in  the  abdominal  wall  in  the  usual  position  for  op- 
erations on  the  gall  bladder  beginning  at  the  ninth  costal  cartilage, 
parallel  to  the  external  border  of  the  rectus  muscle  for  a  distance 
of  two  and  one-half  inches.  The  gall  bladder  is  located,  a  suffi- 
cient surface  of  its  wall  exposed,  the  contents  aspirated,  the  purse- 
string  suture  inserted,  the  gall-bladder  incised,  male  half  of  button 
inserted,  purse  string  tied  and  cut  short;  the  tubular  portion  of 
the  button  is  then  pressed  into  position;  the  tube  is  then  drawn 
out  as  far  as  the  gall  bladder  will  permit  and  held  there  with  a  pin 
passed  through  the  openings  in  the  side.  During  the  time  the 
pressure  atrophy  in  the  portion  of  the  gallbladder  clasped  between 
the  button  is  taking  place,  a  cicatricial  wall  is  being  formed  about 
the  tube  which  acts  as  the  walls  of  a  sinus  after  its  production  and 
insures  continued  protection  to  the  peritoneal  cavity. 

The  following  operations  were  performed: 

Case  I.  Mrs.  K.,  aet.  thirty-five,  several  children.  This  case 
was  referred  to  me  by  Dr.  J.  H.  Hoelscher  who  furnished  the  fol- 
lowing history  :  Four  years  ago  the  patient  was  first  attacked 
with  severe  pain  in  the  region  of  the  gall  bladder,  which  was  soon 
followed  by  nausea  and  vomiting.  This  pain  lasted  several  hours 
and  a  few  days  after  the  onset  the  patient  became  very  much  jaun- 
diced. Tenderness  continued  over  the  gall  bladder  for  ten  days 
or  more  after  the  attack.  Thiese  attacks  occurred  at  frequent  in- 
tervals during  the  past  fouryears;  after  some  of  the  attacks  she 
passed  gall  stones  and  has  a  collection  of  them  on  hand.  About 
two  years  ago  she  had  one  verj^  severe  attack  lasting  much  longer 
than  the  others  and  accompanied  by  more  pain,  fever  and  tender- 
ness. It  took  her  a  long  time  to  rally  from  this  attack.  The  last 
attack,  ten  days  before  operation,  was  followed  by  jaundice  and  a 
few  stones  were  passed.  Not  more  than  half  of  the  attacks  were 
followed  by  jaundice.  She  suffered  very  much  most  of  the  time 
from  digestive  disturbances  and  a  constant  aching  in  the  side. 

Present  Condition. — Patient  a  well  nourished,  stout,  healthy- 


10 

looking  individual.  On  examination  we  find  a  large  sensitive  tumor 
extending,  down  about  three  inches  below  the  right  ninth  costal 
cartilage.  This  tumor  can  be  felt  separate  and  distinct  from  the 
kidney,  and  presses  against  the  abdominal  wall  in  front.  It  moves 
synchronously  with  the  diaphragm  in  respiration. 

Diagnosis. — Cholelithiasis  with  pericystitis.  Operation  by  Dr. 
Murphy,  assisted  by  Drs.  Hoelscher  and  Lee.  Present,  Dr.  Mac- 
Fadden  Gaston,  of  Atlanta;  Dr.  Quimby,  of  Jersey;  Drs.  Cole  and 
Owings,  of  Montana;  Dr.  Jelks,  of  Hot  Springs;  Drs.  Wittwer, 
Hartmann,  E.  H.  Lee,  Conley  and  Oswald.  The  usual  incision 
was  made  at  outer  border  of  rectus.  The  gall  bladder  was  com- 
pletel}^  surrounded  by  adhesions  and  contracted:  it  was  impossible 
to  approximate  it  to  the  abdominal  wall  or  to  any  portion  of  the 
bowel.  It  was  decided  to  put  in  the  drainage  button  tube.  A 
portion  of  the  fundus  of  the  gall  bladder  was  exposed  sufficiently 
large  to  insert  the  button  and  to  place  it  in  position.  A  number  of 
calculi  were  removed  and  many  allowed  to  remain.  The  tube  pro- 
jected above  the  wall  of  the  abdomen,  and  the  wound  outside  was 
packed  with  iodoform  gauze.  The  button  tube  liberated  itself  on 
the  seventh  day,  and  a  number  of  stones  followed.  The  patient 
made  an  uninterrupted  recover}^,  and  is  now  in  excellent  health  ; 
has  a  small  sinus,  but  no  bile  is  escaping,  August  20,  1893.  Sep- 
tember 15,  sinus  closed. 

Case  II.     Mrs.  M ,  set  fifty,  Indianola,  Neb. 

Diagnosis. — Cholelithiasis,  impaction  in  choledochus.  Had  had 
repeated  attacks  of  gall  stone  colic,  accompanied  by  jaundice,  in 
the  last  four  years.  For  the  last  year  the  jaundice  has  been  con- 
tinuous. 

Operation. — November  1,  1893.  Found  gall  bladder  very  much 
contracted;  filled  with  a  dozen  calculi.  Firmly  adherent  through- 
out; evidence  of  old  pericystitis.  Duodenum  adherent.  As  the 
approximation  to  duodeum  could  not  be  made,  the  gall  bladder  was 
incised,  stones  removed  and  the  drainage  tube  button  inserted  and 
packed  around  with  iodoform  gauze.  The  button  tube  liberated 
itself  on  the  tenth  day.  Two  calculi  followed  it,  which  evidently 
had  been  returned  from  the  ducts  into  the  bladder.  Jaundice  dis- 
appeared. Sinus  closed  on  twenty-first  day.  Patient  about  the 
ward  on  twenty-eighth  day.  Discharged  from  the  hospital  De- 
cember 6. 

The  number  of  cases  of  operation  by  incision  and  drainage  in 
literature  is  twenty-three,  with  four  deaths,  a  mortality  of  about 
eighteen  per  cent.     As  this  is  not  an  operation  of  election,  the  pe- 


11 

culiarities  of  the  individual  case  will  be  the  guide  to  the  surgeon  as 
to  when  it  must  be  performed. 

III.  Suture  of  the  Gall  Bladder  with  Secondary  Incision,  Chole- 
cystostoniy  in  Two  Sittings. — The  serous  surface  of  the  gall  bladder 
is  united  to  the  margin  of  incision  in  the  abdominal  wall  and  a  suf- 
ficient time  is  allowed  to  elapse  for  adhesions  to  take  place,  from 
five  to  fifteen  days;  then  an  incision  is  made  in  the  gall  bladder 
and  its  contents  allowed  to  escape.  The  operation  was  first  sug- 
gested by  Carri,  and  executed  by  Blodgett  and  Kocher  in  1878. 
Courvoisier  collected  thirty-two  cases.  Riedel  operated  in  this 
manner  thirty-four  times,  eleven  of  these  are  included  in  Courvoi- 
sier's  report.  I  find  in  the  literature  from  June,  1890,  at  which 
time  Courvoisier's  report  was  published,  to  February  28,  1893,  but 
four  cases,  with  the  exception  of  those  of  Reidel,  twenty-three 
cases,  making  a  total  of  fifty-nine  cases,  with  six  deaths,  or  a  mor- 
tality of  ten  per  cent.  Of  the  patients  that  left  the  hospital,  about 
thirty-four  per  cent  were  discharged  with  a  fistula;  these  had  an 
average  treatment  of  two  and  one-half  months.  Riedel  has  cham- 
pioned this  operation  from  the  beginning  and  has  persistently 
adhered  to  it  while  other  surgeons  have  taken  up  the  operation  of 
one  sitting,  as  shown  by  the  statistics,  only  four  operations  of  this 
kind  being  reported  since  June,  1890.  Bardenheuer,  Langenbuch, 
Mikulicz  and  Lauenstein  have  been  strong  advocates  of  this  ope- 
ration in  the  order  mentioned,  but  have  all  deserted  it,  notwith- 
standing its  favorable  statistics,  leaving  Riedel  alone  its  great 
advocate.  The  indications  for  this  operation  are  the  same  as  for 
cholecystostomy  of  one  sitting,  to  be  mentioned  hereafter. 

IV.  Cholecystostomy  in  One  Sitting,  Suture  with  Immediate  In- 
cision.—The  first  operation  of  this  kind  was  performed  on  July 
15,  1867,  by  Bobb,  who  was  making  a  laparotomy  on  the  diagnosis 
of  ovarian  tumor,  this  being  the  first  laparotomy  opening  of  the 
gall  bladder  and  cholecystostomy  of  one  sitting.  Without  a 
knowledge  of  this  case,  in  the  years  1878  and  ]879,  Marion  Sims, 
W.  W.  Keen  and  Lawson  Tait  performed  the  same  operation 
without  previously  diagnosticating  the  case.  This  operation  was 
named  by  Lawson  Tait  "ideal  cholecystostomy."  It  would  be 
more  appropriately  termed  unnatural  cholecystostomy,  as  it  is  not 
natural  for  the  gall  bladder  to  empty  on  the  surface  of  the  abdo- 
men. The  term  "natural  cholecystostomy"  should  be  reserved  for 
the  operation  known  as  cholecystenterostomy,  because  the  bowel 
is  the  natural  receiver  of  the  contents  of  the  gall  tracts.  From 
that  time  there  have    been   collected  by  Courvoisier  120  cases,  by 


12 

Riedel  12  and  by  myself  69,  making  a  total  of  201  cases.  The 
histories  of  many  of  these  cases  are  very  defective,  first,  as  to  the 
previous  conditions;  second,  as  to  the  status  praesens  and  clinical 
history;  third,  as  to  the  condition  when  discharged.  Tait  operated 
upon  fifty-seven  of  these  cases.  In  the  very  great  majority  he 
leaves  out  all  the  particulars  above  mentioned.  In  many  he  does 
not  mention  whether  the  fluid  contents  of  the  gall  bladder  was 
bile,  hydrops,  or  pus,  and  in  others  he  does  not  mention  even  the 
presence  or  absence  of  stone,  though  this  item  is  less  frequently 
omitted.  I  find  in  163  cases  stones  reported  in  112,  and  in  about 
'75  per  cent  of  these  the  stones  were  situated  only  in  the  gall  blad- 
der; in  about  12  per  cent  in  the  gall  bladder  and  cystic  duct; 
8  per  cent  in  the  cysticus  alone;  3  per  cent  in  the  choledochus, 
and  the  balance  scattering.  In  all  cases  where  found,  the 
stone  was  extracted  from  the  gall  bladder  at  time  of  operation. 
In  other  cases  where  stones  were  situated  in  the  ducts,  a  litho- 
tripsy was  performed  either  by  the  fingers,  by  forceps,  or  bj'^  pass- 
ing a  needle  through  the  wall  of  the  duct  and  fracturing  the  stone. 
In  other  cases  the  stones  were  pressed  onward  out  of  the  duct  into 
the  intestine  or  back  into  the  gall  bladder;  in  still  others  thej^  were 
cut  down  on  in  the  duct  and  removed  through  its  wall.  Of  this  I 
will  speak  later.  The  mortality  in  the  201  cases  of  cholecystostomy 
while  the  patients  were  still  under  treatment,  was  39  or  about  19 
per  cent.  The  number  of  cases  discharged  with  fistula  can- 
not be  approximately  determined  as  Tait's  report  is  incomplete 
and  excluded.  From  other  statistics  we  have  discharged  with 
fistula  about  31  per  cent,  and  with  the  same  exclusion  as  above 
complete  recoveries  51  per  cent.  We  see  that  the  mortalitj^  in  the 
one  sitting  was  less  than  in  the  two  sittings  operation,  in  one  case 
being  10,  and  the  other  19  per  cent,  but  still  the  outcome  as  to  the 
ultimate  complete  recovery  is  approximately  the  same  as  in  the 
operation  of  one  sitting,  and  not  a  promising  one  for  the  patient. 
Still  some  surgeons  have  had  brilliant  results,  and  the  renowned 
Dr.  H.  G.  Marcy,  of  Boston,  says:  "It  is  safe  to  predict  that  the 
future  history  of  operative  measures  for  the  relief  of  biliary  ob- 
structions, will  furnish  one  of  the  most  brilliant  chapters  in 
surgery.  One  of  the  most  serious  of  all  the  abdominal  diseases, 
as  evinced  by  acute  pain,  prolonged  suffering,  and  great  mortality? 
confessedly  without  remedy  b}^  internal  medication,  cholecystost- 
omy offers  help  to  the  hopeless  with  an  attendant  danger  in  the 
hands  of  an  experienced  surgeon  of  as  small  a  percentage  as  in 
ovariotomy." 


13 

Cholecystostomy  by  Means  of  Murphy  Button. — This  operation 
can  be  performed  with  the  anastomosis  button  in  much  less  time 
and  with  much  greater  safety  than  with  suture,  in  the  following 
manner:  The  half  of  the  button  that  is  to  be  introduced  into  the 
gall  bladder  is  first  threaded  by  passing  two  pieces  of  surgeon's 
silk  about  eighteen  inches  long  through  the  four  drainage  openings 
in  the  bowl  of  the  button,  each  thread  being  passed  through  two  of 
the  openings  nearest  one  another,  the  four  ends  of  the  threads  are 
drawn  even  and  then  passed  through  the  cylinder  of  the  button, 
entering  the  cylinder  at  its  junction  with  the  bowl.  This  enables 
traction  to  be  made  on  this  half  of  the  button  after  it  has  been 
placed  in  position  in  the  gall  bladder,  thus  permitting  a  firm  ap- 
proximation and  locking  of  the  two  halves  of  the  button.  The 
threaded  half  of  the  button  is  inserted  into  the  gall  bladder  in  the 
same  manner  as  in  cholecystenterostomy;  an  artery  forceps  is  then 
pushed  through  the  parietal  layer  of  the  peritoneum,  one-half  inch 
to  the  side  of  the  incision,  grasping  the  stem  of  the  button  inserted 
in  the  gall  bladder  and  drawing  the  stem  through  the  opening 
iViade  by  the  artery  forceps;  pass  the  traction  cord  through  the 
other  half  of  button,  draw  the  button  together  and  remove  the 
threads.  Sew  up  original  opening  in  the  peritoneum  with  catgut. 
You  have  now  secured  a  firm,  permanent  approximation  of  the  sur- 
face of  the  gall  bladder  to  the  parietal  layer  of  the  peritoneum. 
The  gall  bladder  will  drain  through  the  button,  and  if  the  button 
drainage  tube  is  used  the  discharge  can  be  brought  to  the  sur- 
face, without  coming  in  contact  with  the  wound.  This  operation 
has  the  advantage  over  the  suture  approximation;  1,  in  the 
great  saving  of  time;  2,  simplicity  and  ease  with  which  it  can 
be  accomplished;  3,  it  insures  perfect  coaptation  and  no  danger  of 
leaking  at  the  side,  or  giving  way,  as  is  the  case  is  with  the  suture 
which  occasionally  causes  death;  4,  it  leaves  a  large  opening.  As 
soon  as  the  pressure  atrophy  is  completed  gall  stones  may  be  ex- 
tracted through  this  opening  and  a  perfect  drainage  kept  up.  I 
am  always  in  favor  of  performing  cholecystenterostomy  where  it 
is  possible,  still  if  the  pathological  conditions  require  a  chole- 
cystostomy, this  is  by  far  the  most  simple,  rapid  and  safe  means  of 
operating, 

V.  Incision,  of  the  gall  bladder,  removing  its  contents,  suturing  it 
to  the  abdominal  wall  with  immediate  extraperitoneal  suture  of  the 
incision  made  in  the  gall  bladder. 

I  am  unable  to  find  but  four  cases  of  this  kind  reported.     The 
operation  has  never  found  great  favor  with  surgeons.      Of  the  four 


14 

cases  operated  on,  three  terminated  successfull}'^,  and  one  fatally,  a 
mortality  of  twenty-five  per  cent.  It  was  intended  to  take  the 
place  of  cholecystendysis,  and  to  diminish  the  danger  by  having 
the  suture  in  the  gall  bladder  extraperitoneal,  so  that  if  the  suture 
should  give  way  or  leak,  the  contents  would  escape  on  the  surface 
instead  of  into  the  peritoneal  cavit)'. 

VI.  Cholecystendysis. — Incision  of  gall  bladder  with  immediate 
suture  and  reposition  into  abdominal  cavity  :  ideal  cholecystotomy. 
This  operation  on  the  gall  bladder  is  a  natural  outgrowth  of  the 
desire  of  laparotomists  to  immediately  and  permanently  close  the 
abdomen  at  the  time  of  the  operation  as  in  the  intraabdominal 
treatment  of  pedicles  in  gynecological  operations.  I  find  thirty- 
five  cases  of  this  kind  in  the  literature,  with  eight  deaths  and 
twenty-seven  recoveries,  a  mortality  of  twenty-three  per  cent. 
The  cause  of  death  was  :  In  one  case  collapse,  in  two  cases  anuria 
with  collapse,  three  with  high  fever  and  peritonitis.  All  of  the 
immediately  fatal  cases,  six,  or  seventeen  per  cent,  terminated  with- 
in seventy-two  hours  after  the  operation.  The  remaining  two  ter- 
minated later.  What  was  most  feared  in  this  operation  was  that 
the  stitches  would  give  way  under  the  tension  of  the  gall  pressure 
and  that  the  contents  of  the  gall  bladder  would  escape  into  the 
peritoneal  cavity.  Langenbuch  and  Tait  were  very  loud  in  their 
declaration  that  this  accident  would  occur,  and  Tait  in  his  article 
in  the  Edinburgh  Medical  Journal,  October,  1889,  stated  that  the 
operation  terminated  fatally  in  every  instance,  while  in  reality  up 
to  that  time  there  had  been  sixteen  operations,  with  ten  recoveries, 
and  in  not  one  of  them  did  the  accident,  "giving  way  of  sutures," 
as  Langenbuch  and  Tait  had  predicted,  occur.  This  is  a  very 
noticeable  illustration  of  an  error  of  common  occurrence.  It  shows 
how  erroneous  the  opinions  of  great  men  in  surgery  may  be  on 
operations  suggested  and  performed  which  are  not  in  line  or  in 
harmony  with  the  ones  they  are  accustomed  to  perform,  the  calam- 
ity which  they  so  forcibly  predicted  and  deemed  inevitable  was  the 
one  that  never  occurred.  While  the  cause  of  death  was  not  from 
giving  way  of  sutures  the  mortality  was  great,  being  about  one- 
third  of  all  cases  operated  on.  This  great  mortality  has  rapidly 
told  against  the  operation,  so  that  it  is  now  rarely  performed  and  is 
not  to  be  recommended. 

VII.  Cholecystenterostomy.  Gall  Bladder  and  Intestinal 
Fistula — Gall  Bladder  and  Intestinal  Anasto/nosis. — The  idea  of  this 
operation  was  suggested  by  nature  in  establishing  pathologically 
a  fistula  between  the  gall  bladder  and  the  intestines.      In  this  way 


15 

the  surgeon  was  guided  to  the  best  means  of  relief  where  an  occlu- 
sion of  the  duct  was  produced  by  the  pressure  of  an  impacted  con- 
crement,  a  neoplasm,  a  cicatricial  band,  or  any  pathological  lesion 
which  would  render  the  common  duct  impervious.  While  nature 
had  thus  blazed  the  way,  surgeons  were  slow  to  take  advantage  of 
its  suggestion.  The  first  one  to  advise  this  method  was  my  late 
friend,  the  lamented  von  Nussbaum,  of  Munich  in  1880.  He  ex- 
pressed himself  in  the  following  words:  "When  the  escape  of  gall 
through  the  natural  duct  is  no  more  possible,  the  question  arises 
can  we  not  make  an  artificial  connection  between  the  gall  bladder 
and  intestines  through  which  the  gall  can  again  escape  into  the 
intestinal  tract,"  etc. 

The  first  to  work  out  a  feasible  plan  for  the  attainment  of 
this  ideal  result  was  von  Winiwarter.  Between  the  20th  of  July, 
1880,  and  the  14th  of  November,  1881,  he  had  under  his  care  a 
man,  with  occlusion  of  the  ductus  choledochus,  on  which  he  oper- 
ated six  different  times,  and  finally  succeeded  in  establishing  a 
fistula  between  the  colon  and  the  gall  bladder,  after  16  months  of 
labor.  His  original  plan  was  to  perform  the  operation  in  two  sit- 
tings, but  all  sorts  of  difficulties  beset  his  way.  It  is  wonderful 
what  energy  and  persistence  both  the  operator  and  patient  showed 
to  overcome  all  impediments.  After  the  publication  of  his  most 
difficult  task  it  was  six  years  and  a  half  before  a  surgeon  was  found 
who  had  the  courage  to  undertake  a  similar  operation,  when  Kappe- 
ler  undertook  to  follow  in  the  footsteps  of  Winiwarter,  but  to  do 
the  operation  in  one  sitting. 

In  the  meantime  there  were  several  experiments  made  on  ani- 
mals, with  the  hope  of  discovering  a  means  of  making  a  communi- 
cation between  the  gall  bladder  and  the  intestine  at  one  sitting. 
Dr.  McFadden  Gaston,  in  1883,  experimented  on  five  dogs,  with 
elastic  suture,  which  was  so  placed  as  to  approximate  the  gall  blad- 
der and  intestines,  and  around  this  a  row  of  serous  sutures  to  pro- 
tect the  peritoneum.  He  hoped  by  the  elastic  pressure  to  produce 
an  atrophy  and  establish  a  fistula.  The  results  were  unfavorable. 
In  one  the  dog  escaped;  two  ended  in  peritonitis;  one  in  abscess 
between  coils  of  intestine — here  the  ligature  sloughed  through  into 
the  gall  bladder,  and  left  but  an  extremely  small  opening;  and  in 
one,  at  the  end  of  the  eleventh  day,  there  was  found  sufficient  ad- 
hesion and  the  fistula  was  established,  the  ligature  being  found  in 
the  intestine.  In  1884  he  used  a  similar  ligature  on  a  young  dog, 
in  the  same  manner,  with  a  good  result.  In  1886  he  made  several 
similar  experiments,  with  the  addition  of  ligatingthe  common  duct, 


1(1 

but  the  dogs  ouly  lived  a  few  days,  dying  of  extensive  gall  infiltra- 
tion in  the  liver.  He  deserves  great  credit  for  energy  and  inge- 
nuity as  a  pioneer  in  this  field. 

G.  Harley  suggested  the  approximation  with  the  formation  of 
fistula  from  the  gall  bladder  to  the  intestine  by  means  of  sutures 
and  caustic  potash.  He  arranged  a  number  of  sutures  in  a  small 
circle,  about  the  size  of  a  dollar,  holding  the  gall  bladder  to  the 
bowel,  but  before  completing  the  circle  mentioned,  cauterized  the 
center  with  caustic  potash,  then  completed  the  circle  with  sutures, 
and  in  that  way  hoped  to  produce  a  fistula  of  the  gall  bladder  and 
hava  an  adhesion  by  plastic  exudation  surrounding  it.  He  claims 
to  have  had  good  success  in  animals. 

Colzi,  in  1883,  put  in  a  circle  of  sutures  similar  to  Harley's, 
but  before  the  final  suture,  made  an  incision  in  the  center  into  the 
gall  bladder  and  duodenum,  also  ligating  the  choledochus.  The 
animals  tolerated  the  operation  without  any  apparent  disturbance 
in  the  digestive  functions. 

De  Page,  in  188*7,  performed  the  same  experiment  as  Colzi,  on 
three  dogs,  without  ligating  the  choledochus.  In  one  the  dog  ran 
away;  another  died  of  peritonitis;  the  third  was  killed  at  the  end 
of  six  weeks  and  showed  an  atrophy  of  the  gall  bladder,  but  no 
fistula.  Finally,  Dastre,  in  his  communication  to  the  Physiological 
Congress  at  Basel,  in  1889,  published  his  experiments,  wherein  he 
succeeded  in  uniting  the  gall  bladder  to  the  intestine  for  the  pur- 
pose of  studying  what  effect  it  would  have  on  digestion.  Of  this 
I  shall  speak  later. 

So  that  we  see  to  the  date  ^bove  mentioned  experiments  rep- 
resented three  different  t5'pes.  1.  The  formation  of  fistula  by 
chemical  destruction.  2.  By  pressure  atrophy,  the  elastic  ligature. 
3.  Careful  suturing  with  subsequent  incision  within  the  circle  pro- 
duced by  the  sutures. 

The  priority  of  the  operation  certainly  belongs  to  Monastyrski, 
for  he  performed  his  operation  about  a  month  before  Kappeler,  but 
did  not  publish  it  until  eleven  months  after  the  operation.  Of  the 
seven  operations  performed,  four  were  for  carcinoma  of  the  head 
of  the  pancreas,  one  for  carcinoma  of  the  duct  at  its  orifice,  and 
two  were  for  impaction  of  gall  stones;  those  of  Terrier  and  Cour- 
voisier.  The  technique  in  all  of  the  above  described  operations 
was  somewhat  similar,  the  suture  being,  used  as  the  means  of  ap- 
proximation. Terrier  used  a  rubber  tube  to  keep  the  opening  patu- 
lous which  was  passed  on  the  eighth  day.  The  seat  of  the  operation 
in  Terrier's  case  was  the  duodenum;  in  JNIonastyrski's,  the  jejunum. 


\1 

2  in.  below  the  duodenum;  in  Kappeler's,  226  ctm.  above  the  cecum; 
in  Fritsche's  case  3  in.  below  the  pylorus. 

There  remain  the  cases  of  Bardenheuer,  who  performed  two 
operations  where  he  united  the  gall  bladder  to  the  small  intestine 
with  an  elastic  suture  in  the  center  and  a  single  row  of  silk  sutures 
around  it,  expecting  that  the  elastic  suture, would  produce  a 
pressure  atrophy,  and  that  a  fistula  would  remain.  The  first  case, 
impacted  gall  stones,  terminated  fatally  at  the  end  of  four  weeks, 
and  the  fistula  was  not  yet  established,  nor  had  the  gall  bladder  ad- 
hered to  the  intestine,  a  biliary  fistula  opening  into  the  peritoneal 
cavity.  The  second  he  writes  to  Terrier,  was  done  in  the  same 
way,  with  the  same  result.  To  this  list,  taken  from  Courvoisier, 
may  be  added  two^^by  Czerny,  one  of  which  died  of  hemorrhage, 
and  the  other  from  exhaustion;  one  by  Helfreich  and  one  by  Reclus, 
making  up  to  date,  November,  1892,  in  all  thirteen  cases  of   chole- 


FiGURE  2. — Anastomosis  Button. 

cystenterostomy  of  one  sitting.  Of  these  six  died  as  the  result 
of  operation — Fritzsche's,  two  of  Bardenheuer,  two  of  Czerny,  one 
of  Korte,  five  died  as  the  result  of  the  malignant  disease  from  which 
they  were  suffering;  and  two  survived.  Terrier's  and  Courvoisier's; 
making  a  mortality  of  forty-six  per  cent  as  an  immediate  result  of 
the  operation. 

Since  November,  1893,  I  have  collected  twenty-three  cases 
with  eight  deaths;  mortality  thirty-five  per  cent. 

The  various  operators  in  commenting  on  the  technique  of  the 
operation,  all  agree  that  it  is  one  of  extreme  difficulty;  and  while 
the  experience  of  the  others  was  not  as  trying  as  that  of  Wini- 
warter, it  was  always  most  difficult  of  performance  with  suture 
and  occupied  an  hour  or  upward  to  complete  the  operation. 

While  reading  of  the  great  difficulties  experienced  by  the  op- 
erators mentioned  in  performing  this  operation,  I  realized  that  the 
profession  was  sorely  in  need  of  some  more  simple  and  perfect 
means  for  the  approximation  of  the  gall  bladder  and  the  intestine; 
and,  after  trying  several  devices,  I  succeeded  in  producing  and  per- 


18 


fecting  the  anastomosis  button,  which  I  think  fulfills  all  of  the  indi- 
cations, Fig.  2.  The  button  is  inserted  in  the  following  manner: 
An  incision  is  made  from  the  edge  of  the  rib,  two  inches  to 
the  right  of,  and  parallel  to,  the  median  line,  extending  downward 
three  inches.  The  gall  bladderis  drawn  into  the  wound,  also  the 
duodenum.  The  duodenum  is  cleared  of  its  contents  b}^  gentle 
pressure  with  the  fingers.  My  short  intestinal  compression  forceps 
are  placed  upon  the  duodenum  to  prevent  the  escape  of  gas  and 
fluids  after  the  incision  is  made.  A  needle  with  fifteen  inches  of 
silk  thread  is  inserted  in  the  duodenum,  directly  opposite  its 
mesenter}^  and  at  a  point  near  the  head  of  the  pancreas.  A  stitch 
is  taken  through  the  entire  wall  of  bowel,  one-third  the  length  of 
the  incision  to  be  made.  The  needle  is  again  inserted  one-third 
the  length  of  the  incision  from  its   outlet,  in  a   line  with    the  first, 


Figure  3. — Intestinal  Compression  Forceps. 

and  brought  out  again,  embracing  the  same  amount  of  tissue  as 
the  first.  A  loop  three  inches  long  is  held  here,  and  the  needle  is 
inserted  in  a  similar  manner,  making  two  stitches,  parallel  to  the 
first,  in  the  reverse  direction,  and  one-eighth  of  an  inch  from  it, 
coming  out  at  a  point  near  the  original  insertion  of  the  needle. 
This  forms  a  running  thread,  which,  when  tightened,  draws  the  in- 
cised edge  of  the  bowel  within  the  cup  of  the  button.  In  the  gall 
bladder  a  similar  running  thread  is  inserted.  Fig.  4.  An  incison  is 
now  made  in  the  intestine,  in  length  two-thirds  of  the  diameter  of 
the  button  used.  One  part  of  the  button  is  slipped  in,  the  running 
string  tied,  and  the  button  held  with  the  forceps.  The  contents 
of  the  gall  bladder  is  withdrawn  with  an  aspirator.  An  incision  is 
then  made  in  the  gall  bladder  the  same  length,  and  between  the 
rows  of  sutures,  the  other  part  of  the  button  is  inserted  in  a  similar 


19 


manner,  and  the  running  string  tied.  The  forceps  are  removed  and 
each  half  of  button  held  between  the  fingers  and  pressed  together, 
Fig.  5.  'A  sufficient  degree  of  pressure  must  be  used  to  bring  the  ser- 
ous surfaces  of  the  gall  bladder  and  intestine  firmly  in  contact  and 
compress  the  tissues.  The  elastic  pressure  of  the  spring  cup  of 
the  button  produces  a  pressure  atrophy  of  the  tissue  embraced 
within  the  cup,  and  leaves  an  opening  as  large  as  the  button,  the 
button  dropping  into  the  bowel  and  being  passed  through  the  in- 
testines. 


Figure  4. — Running  threads  in  position  in  gall  bladder  and  duodenum. 

It  takes  about  as  long  to  describe  the  operation  as  to  perform 
it.  The  time  occupied  with  the  first  patient  on  whom  I  operated 
was  eleven  minutes,  from  the  entering  of  the  peritoneal  cavity  until 
the  closing  of  it.  On  dogs  I  was  from  eleven  to  eighteen  minutes 
in  performing  the  operation,  the  latter  time  being  on  the  first  dog, 
before  I  had  made  the  various  improvements  in  the  technique  and 
button.  The  operation  is  more  difficult  to  perform  on  the  dog  than 
on  man,  as  it  is  more  difficult  to  bring  the  gall  bladder  into  the 
wound. 

To  show  that  this  operation  is  one  that  the  busy  surgeon  will 
be  frequently  called  upon   to  perform,  now    that  the  technique  is 


20 


simple,  we  have  only  to  reflect  on  the  number  of  cases  of  chronic 
jaundice  from  obstruction  of  the  common  gall  duct,  requiring  some 
operation  for  relief,  and  to  draw  attention  to  the  defects  of  the  op- 
erations now  in  vogue,  namely,  the  unpleasant  and  sometimes  dan- 
gerous sequence  of  cholecystostomy,  an  external  biliary  fistula, 
which    may   of  itself    be  a  menace  to  life,    and    require   a  second 


Figure  5. — Method  of  controlling  the  two  halves  of   button  while 
approximating. 

operation  even  more  critical  than  the  first,  as  is  shown  in  the  re- 
ports by  Courvoisier;  also  the  difficulties  and  dangers  of  cholecyst- 
ectomy and  cholecystendysis. 

When  we  consider  that  in  cholecystostomy  patients  re- 
quire two  operations  and  that  the  quantity  of  bile  discharged  in 
each  case  requires  at  least  two  dressings  a  day  for  two  and  one- 
half  months,  representing  an  enormous  amount    of   labor  for    the 


21 

surgeon  and  attendants  and  a  very  protracted  and  unpleasant  con- 
valescence for  the  patient;  also,  when  we  consider  that  but  fifty- 
one  per  cent  left  the  hospital  with  complete  recovery,  we  can  see 
how  very  much  the  profession  is  in  need  of  some  better  plan  of  treat- 
ment of  the  lesions  of  the  gall  tracts  than  cholecystostomy  by 
one  or  two  sittings.  Take  into  consideration  also  the  injurious  ef- 
fects of  a  permanent  fistula  and  we  have  another  very  potent  reason 
for  abolishing  the  external  opening. 

The  effect  of  a  permanent  fistula  of  the  gall  bladder  and  con- 
stant escape  of  bile  secreted,  as  frequently  follows  cholecystostomy, 
is  different,  depending  first,  on  the  quantity  of  bile  that  escapes 
from  the  opening,  and,  second,  on  what  proportion  is  admitted  in- 
to the  intestinal  tract.  These  facts  have  been  lost  sight  of  by 
many  of  the  surgeons  that  have  operated  and  had  an  external 
fistula  remain,  which  accounts  for  the  great  differences  of  opinion 
as  to  the  gravity  of  a  biliary  fistula.  Where  the  fistula  of  the  gall 
bladder  allows  only  a  portion  of  the  bile  to  escape,  the  patient  and 
animal,  as  in  Dastre's  experiments,  can  live  without  suffering  from 
the  loss;  that  is,  they  are  capable  of  digesting  with  a  much  smaller 
quantity  of  bile  than  they  naturally  secrete.  But  if  we  let  the  en- 
tire quantity  of  bile  escape  through  a  fistula,  the  patient  soon 
succumbs.  This  is  thoroughly  demonstrated  by  the  twelve  cases 
collected  by  Courvoisier.  All  patients  died  where  the  entire 
quantity  of  bile  secreted  escaped  through  the  fistula,  and  where  a 
large  proportion  escaped  the  patients  became  emaciated  and  sick. 
Therefore  a  safe  means  of  allowing  the  bile  to  reenter  the  intes- 
tines should  be  welcomed  by  the  surgeon  and  patient.  This  opera- 
tion will  produce  the  same  favorable  revolution  in  the  surgery  of  the 
gall  bladder  that  the  intraabdominal  treatment  of  the  pedicles  did 
in  the  treatment  of  tumors  of  the  uterus  and  its  appendages. 

Why  should  a  gall  bladder  be  sutured  to  the  abdominal  wall 
and  drained  any  more  than  an  ovarian  cyst  should  be  treated  in 
this  manner  ? 

There  are  reported  in  all  up  to  December,  1893,  twent)'-three 
cases  operated  on  in  one  sitting  all  b}^  means  of  sutures,  with  a 
mortality  in  this  operation  of  thirty-five  per  cent,  or  eight  deaths 
in  twenty-three  cases.  From  the  11th  of  June,  1892,  up  to  Febru- 
ary 13,  1894,  there  have  been  twenty  operations  of  cholecysten- 
terostomy  by  means  of  the  anastomosis  button  for  the  relief  of 
cholelithiasis,  with  twenty  recoveries,  100  per  cent,  one  each  by 
Dr.  E.  W.  Lee,  Chicago;  Dr.  W.  J.  Mayo,  of  Rochester,  Minne- 
sota; Dr.  A.  H.  Fabrique,  of  Wichita,  Kan. ;  Dr.  Alex.  H.  Ferguson, 


22 

Winnepeg,  Manitoba;  Dr.  W.  B.  Rodgers,  Memphis,  Tenn.; 
Dr.  T.  D-.  Lane,  Media,  Penn.;  Dr.  Wm.  D.  Foster,  Kansas  Cit}'; 
Dr.  J.  H.  Dunn,  Minneapolis;  Dr.  M.  H.  Luken,  Chicago;  two 
by  Dr.  F,  S.  Hartmann,  Chicago,  and  nine  by  myself.  In  all  of 
these  cases  the  result  has  been  a  complete  restoration  to  health 
and  no  recurrence  of  symptoms,  as  will  be  seen  by  the  histories. 
I  have  had  all  of  my  cases  and  those  of  Drs.  Lee  and  Hartmann 
visited  in  the  last  week,  and  the}^  are  all  in  excellent  health;  in  not 
one  did  the  symptoms  return  as  was  feared  by  Dr.  Abbe.  There 
was  one  operation  by  this  method,  by  myself,  in  which  the  lesion 
was  carcinoma  of  the  pancreas.  The  duodenum  was  involved  in 
the  carcinoma  and  could  not  be  used  in  approximation,  a  loop  of 
the  small  intestine  was  drawn  into  the  opening  in  the  abdomen  and 
approximated  to  the  gall  bladder  with  the  button,  and  the  patient 
died  at  the  end  of  the  fouith  day.  The  post-mortem  showed  the 
button  in  position.  It  was  found  that  the  bowel  had  been  twisted 
upon  itself  in  the  operation  and  a  complete  obstruction  produced 
the  same  as  in  volvulus.  This  accident  is  an  impossibility  if  the 
duodenum  is  used  for  the  approximation,  and  I  wish  to  call  special 
attention  to  its  liability,  as  it  is  so  easily  avoided  when  it  is  antici- 
pated. There  was  a  cancer  in  this  involving  the  greater  portion 
of  the  pancreas,  including  the  duodenum,  and  the  common  duct. 
The  period  of  convalescence  was  in  all  cases  very  short  and  the 
patients  were  not  seriously  sick  immediately  after  the  operation. 

This  operation  is  indicated  :  1,  in  all  cases  where  it  is  desira- 
ble to  drain  the  gall  bladder  for  accumulations  therein  ;  2,  in  all 
cases  of  perforation  of  choledochus  into  abdominal  cavity  where 
the  duct  must  be  obliterated  by  the  reparative  process  ;  3,  in  all 
cases  of  cholelithiasis  where  obstruction  of  ducts  is  present,  or 
where  the  reflex  disturbances  of  digestion  are  marked  ;  -i,  in  all 
cases,  of  cholecystitis  either  with  or  without  gall  stones;  5,  and  in 
all  profusel}'  discharging  biliary  fistulae,  either  following  operations 
or  as  sequelae  of  pathological  changes  in  gall  tract. 

The  cases  in  which  this  operation  should  not  be  performed 
are  :  a,  all  cases  where  the  gall  bladder  is  too  small  for  the  inser- 
tion of  the  button  ;  b,  where  the  adhesions  are  so  extensive  that 
the  bowel  cannot  be  brought  into  contact  with  the  gall  bladder 
without  kinking  ;  c,  where  the  ductus  cysticus  is  obliterated,  in 
which  cases  the  operation  of  cholec3^stectomy  should  be  performed 
where  there  is  an  absence  of  adhesions  around  the  gall  bladder  ;  d, 
where  we  have  an  enormously  enlarged  gall  bladder  with  an 
elongation  of    the  ductus  cysticus,  and  without  an   obstruction  in 


23 

the  ductus  choledochus,  in  which  case  cholecystectomy  should  be 
performed.  If  the  ductus  choledochus  be  occluded,  the  gall  blad- 
der should  be  amputated  just  above  the  neck,  leaving  a  sufficient 
portion  in  vi^hich  the  button  can  be  inserted  in  the  end,  and  the 
approximation  made  to  the  duodenum  in  the  usual  way.  By  this 
operation  we  provide  again  a  channel  for  the  escape  of  the  bile 
into  the  intestinal  canal. 

REPORT  OF  CHOLECYSTENTEROSTOMIES  BY  MEANS  OF  THE 
ANASTOMOSIS  BUTTON. 

Case  I.      A.  Q ,  age  thirty-five,  female;   admitted   to  the 

medical  department  of  Cook  Count)^  Hospital,  May  27,  1892. 
Transferred  to  the  surgical  division  of  the  hospital,  June  10,  1892, 
and  came  under  my  care.  Gave  the  following  history  :  During 
the  last  fifteen  years  has  had  stomach  troubles  ]  pain  and  tender- 
ness in  the  epigastrium  ;  the  attack  would  last  from  two  to  four 
days,  was  almost  always  accompanied  by  vomiting,  not  by  jaun- 
dice. Had  pain  in  back  since  childbirth;  suffered  from  chronic 
constipation.  One  of  these  attacks  was  accompanied  by  jaun- 
dice, December  14,  1891.  At  that  time  had  constant  and  intense 
pain  for  twelve  hours,  and  an  aching  pain  and  tenderness  in  the 
epigastrium  for  two  months  following  it.  Jaundice  cleared  in  about 
two  months.  During  the  past  few  months  the  attacks  of  stomach 
trouble  would  last  from  twelve  to  twenty-four  hours.  In  February 
the  present  attack  began,  accompanied  by  jaundice  and  severe 
pruritus,  which  has  been  constant  from  that  time  up  to  date. 
These  symptoms  increased  in  severity  up  to  the  time  she  was 
admitted  into  the  hospital.  While  in  the  medical  department  her 
jaundice  was  constant  ;  her  mental  condition  became  very  much 
impaired,  and  her  emaciation  rapidly  increased. 

Condition  when  admitted  to  the  Surgical  Department:  The 
patient  intensely  jaundiced  ;  very  much  emaciated  ;  has  a  point 
of  tenderness  in  the  right  hypochondriac  region  just  below  the 
margin  of  the  rib  ;  no  tumor  to  be  felt.  The  urine  contains  a 
large  quantity  of  bile,  no  albumin.  The  patient  suffers  from 
considerable  mental  derangement,  very  slight  elevation  of  tem- 
perature. 

Operation  June  1 1,  1892.  I  decided  to  perform  cholecj'stenter- 
ostomy  by  means  of  an  anastomosis  button,  which  device  I  had  used 
for  the  first  time  on  a  dog,  six  days  previous.  An  incision  three  inches 
long  was  made,  three  inches  to  the  right  of  the  median  line,  extend- 


24 

ing  directly  downward.  The  gall  bladder  was  found  distended, 
nonadherent,  and  contained  a  large  number  of  small  calculi.  Two 
calculi  were  found  in  ductus  choledochus  and  allowed  to  remain. 
Duodenum  and  gall  bladder  were  both  drawn  into  the  wound;  an  in- 
cision was  made  in  the  duodenum  and  half  of  the  button  inserted.  A 
running  thread  was  put  in  the  gall  bladder,  an  incision  made, 
and  the  other  half  of  the  button  inserted.  The  gallstones  were  not 
removed.  There  was  considerable  escape  of  bile,  as  gall  bladder 
was  not  aspirated  before  putting  in  the  button.  The  button  was 
then  pressed  together  without  any  difficulty,  and  the  mass  dropped 
into  the  abdominal  cavity.  Time  from  the  opening  of  the  perito- 
neum until  the  closing  of  same,  eleven  minutes.  After  the  opera- 
tion the  patient  showed  no  unpleasant  symptoms  ;  temperature  at 
no  time  exceeded  100°  F.,  and  in  fourteen  days  from  the  operation 
she  was  allowed  to  walk  about  the  ward.  The  jaundice  rapidly 
disappeared,  and  three  weeks  after  the  operation  there  was  no 
trace  of  bile  in  the  urine.  The  patient  was  of  a  very  hysterical 
temperament  after  her  mental  condition  improved  ;  she  noticed 
that  she  was  an  object  of  observation  and  became  so  erratic  that 
we  could  not  control  her  at  the  hospital,  and  were  compelled  to 
discharge  her  five  weeks  after  the  operation.  Up  to  that  time  she 
stated  that  she  had  "not  passed  the  button."  She  was  apparently 
well  in  every  particular.  The  button  used  in  this  case  was  very 
imperfect  compared  with  the  improved  one  now  used. 

October  28,  1892.  Patient  was  examined  by  Dr.  H.  R. 
Wittwer.  He  found  the  jaundice  had  not  returned;  there  was  no 
bile  in  the  urine,  and  the  patient  was  in  excellent  health.  He 
could  not  ascertain  whether  she  had  passed  the  button  or  not. 

In  December,  1892,  this  patient  began  to  suffer  from  pain 
in  the  right  side  and  temperature  which  continued  to  Januar}^ 
1893.  She  was  in  one  of  the  hospitals  in  this  city.  An  explor- 
atory operation  was  made  over  the  site  of  the  former  operation, 
a  contracted  gall  bladder  was  found  firml}^  and  perfectly  united 
to  the  duodenum.  Subsequentl}'  the  cause  of  the  temperature 
was  found  to  be  an  abscess  of  the  lung,  not  an  empyema, 
which  was  drained,  and  the  temperature  at  once  disappeared.  At 
no  time  since  the  first  operation  has  the  patient  been  jaundiced, 
nor  has  there  been  bile  in  the  urine. 

Case  II.  The  following  case  was  referred  to  me  by  Dr. 
Hoelscher,  who  with  Drs.  Wiener  and  Lee,  assisted  me  in  the 
operation.      Mrs.  B ,  age  thirty-eight,   widow,  three    children. 


25 

Parents  still  alive,  aged  seventy-six  and  seventy-four  respectively. 
Brothers  and  sisters  well;  no  history  of  any  hereditary  disease. 

Dr.  Hoelscher  saw  the  patient  for  the  first  time  October  Y, 
1892,  and  found  her  as  follows:  "  Healthy,  well  nourished  appear- 
ance; pain  of  sudden  onset  in  the  epigastric  region,  and  from  this 
point  it  gradually  extended  over  the  whole  abdomen.  She  had 
vomited  the  contents  of  the  stomach  and  some  bile  on  two  oc- 
casions after  the  seizure  with  pain.  Bowels  were  constipated  and 
had  been  in  this  condition  two  or  three  days  before  the  attack. 
Vesical  tenesmus  and  diminished  quantity  of  urine.  Gave  no  his- 
tory of  any  previous  pain,  gastric  disturbance,  jaundice  or  colics." 

On  examination  found  a  tumor  in  right  hypochondriac  region, 
■extending  downward  into  the  iliac  region  and  terminating  in  a 
rounded  smooth  end  ;  could  be  distinctly  felt  in  lumbar  region,  was 
movable  and  tender  on  pressure;  there  appeared  to  be  a  deep  fis- 
-sure  between  the  tumor  and  the  liver,  no  fluctuation  apparent, 
bowel  or  colon  not  overlying  the  tumor.  The  diagnosis  could  not 
be  determined,  but  it  was  presumed  to  be  some  lesion  of  the  kid- 
ney, so  it  was  decided  to  make  an  exploratory  laparotomy. 

Operation,  October  19,  1892.  I  made  an  incision  three  inches 
long,  from  the  edge  of  the  tenth  rib  directly  downward  toward  the 
border  of  the  ilium.  The  tumor  was  exposed  and  found  to  be  a  very 
much  enlarged  gall  bladder  containing  large  calculi.  The  viscus 
was  edematous,  red  and  thickened.  It  was  decided  to  make  a  chole- 
•cystenterostomy  with  the  anastomosis  button.  No.  2.  The  gall  blad- 
der was  aspirated,  and  the  running  thread  inserted.  The  running 
thread  w^as  then  inserted  into  the  duodenum  and  the  intestine  in- 
cised and  the  male  half  of  the  button  placed  in  position;  the  female 
half  was  then  placed  in  the  gall  bladder  through  a  slit  made  be- 
tween the  running  thread,  and  the  button  closed.  The  gall  blad- 
der measured  at  least  one  centimeter  in  thickness  and  was  very 
edematous.  There  was  no  difjficulty  in  inserting  the  button.  The 
gallstones  were  allowed  to  remain,  as  I  do  not  consider  it  neces- 
sary to  remove  them  unless  the}^  are  larger  than  the  button.  They 
will  pass  out  after  the  button  escapes. 

October  20.  Temperature,  101°  F.;  pulse,  96.  Vomited  con- 
siderably during  the  night  and  complained  of  headache,  which 
seemed  to  be  effects  of  anesthetic.  There  was  no  pain  nor  ab- 
•dominal  tenderness. 

October  21.  At  5  P.  M.  yesterday  the  vomiting  ceased,  and 
the  patient  is  feeling  very  well  this  morning. 

October  27.      The   patient   has    had  no   unpleasant  symptoms 


26 

since  October  20.  This  morning,  eight  da3's  after  the  operation, 
two  large  gallstones  were  found  in  the  stool.  The  larger  one 
weighed  llV  grains,  1.8  gni.;  its  longest  diameter  one  inch,  its 
shortest  seven-eighths  inch.  The  second  stone  102  grains,  6.  8 
gm.;  its  longest  diameter  seven-eighths  inch,  its  shortest  three- 
fourths  inch.  It  will  be  noticed  that  the  shortest  diameter  of  the 
larger  stone  measures  exactly  the  same  as  the  diameter  of  button 
used.  The  patient  is  feeling  very  well  and  is  sitting  up  in  bed. 
Complete  primary  union.  Button  passed  eighteen  days  after  op- 
eration. 

August  20,  1803.  The  patient  has  excellent  health  and  not 
the  least  symptom  of  her  previous  trouble. 

Case     IH.       This    case    was    referred    to    me   by    Dr.   J.    H. 

Hoelscher,  who  gave   me  the  following  history  :   "Mrs.  Z ,  age 

thirty-six,  married,  six  children.  Enjoyed  perfect  health  until 
twenty-two  years  of  age;  at  that  time,  three  months  after  childbirth, 
had  an  attack,  of  short  duration,  of  severe  epigastric  pain  and 
vomiting.  It  was  not  accompanied  or  followed  by  jaundice.  Ever 
since  that  attack  she  has  had  digestive  disturbances,  as  distress 
following  certain  kinds  of  food,  eructations  of  gas,  constipation, 
loss  of  appetite.  Four  37ears  ago  she  had  a  similar  attack  of 
pain  in  the  epigastrium,  accompanied  by  vomiting.  From  that 
time  on  the  pain  returned  every  five  or  six  weeks,  up  to  five 
months  ago,  when  she  noticed  a  constant  aching  pain  and  tender- 
ness in  the  right  hypochondriac  region,  that  persisted  until  the 
present  time.  The  pain  and  soreness  was  very  much  increased 
after  working  in  a  stooping  posture.  She  has  suffered  much  from 
general  debility,  and  complains  frequently  of  slight  chills. 
Throughout  the  entire  progress  of  her  disease  jaundice  was 
never  present.  The  urine  was  tested  several  times  with  nega- 
tive results.  She  does  not  give  a  distinct  history  of  having 
had  hepatic  colic. 

"About  three  months  ago  she  found  small  particles  the  size  of 
mustard  seeds,  in  the  feces,  which  some  one  told  her  were  gall- 
stones. There  is  no  positive  evidence  that  she  ever  passed  a  gall- 
stone. Physical  examination  revealed  heart  and  lungs  normal; 
liver  not  increased  in  size.  Manipulation  reveals  a  pear  shaped, 
hard  tumor  in  the  region  of  the  gall  bladder,  measuring  about  three 
inches  in  length,  and  two  in  width.  It  moves  synchronously  with 
the  diaphragm  in  respiration.  On  pressure  considerable  pain  is 
produced,  and  a  slight   creaking  sensation  is   felt  by  the  fingers. 


27 

It  can  be  separated  from  the  kidney,  and  can  be  moved  considera- 
bly from  side  to  side." 

The  diagnosis  of  gallstone  was  made  by  Dr.  Hoelscher,  and 
the  case  was  referred  to  me  for  operation. 

Operation,  November  23,  1892.  Assisted  by  Drs.  Hoelscher 
and  Lee,  in  the  presence  of  Dr.  Nicholas  Senn,Dr.  Dunn,  of  Min- 
neapolis and  Drs.  W.  J.  and  C.  H.  Mayo,  of  Rochester,  Minn. 
The  incision  was  made  the  same  as  in  Case  II.;  a  contracted 
gall  bladder  packed  full  of  gallstones,  slipped  into  the  wound. 
A  little  difificulty  was  experienced  in  drawing  the  duodenum  for- 
ward, as  some  old  adhesions  existed.  The  running  threads 
were  inserted  in  gall  bladder  and  duodenum  ;  male  half  of  button 
placed  in  duodenum,  and  held  by  an  assistant.  An  incision  was 
made  in  the  gall  bladder,  which  was  found  so  full  of  gallstones 
that  half  of  the  button  could  not  be  inserted  without  removing 
some  of  them.  A  dozen  were  quickly  picked  out  with  the  dissect- 
ing forceps.  About  twice  as  many  were  allowed  to  remain.  The 
female  half  of  the  button  was  inserted  in  the  gall  bladder,  and  the 
running  thread  tied.  Button  pressed  together.  Toilet  of  field  of 
operation  was  made  with  dry  gauze,  and  the  viscera  dropped 
back  into  the  abdomen.  Deep  and  superficial  rows  of  sutures  in 
abdominal  wall.  Time  for  entire  operation  twenty-one  minutes. 
The  time  for  inserting  the  button  was  not  taken.  Patient  rallied 
rapidly  from  the  anesthetic.  Pulse  after  operation  70  ;  tempera- 
ture normal.     Neither  nausea  nor  vomiting. 

November  25.  Pulse,  78;  temperature,  100.5°  F.  Patient 
complains  of  slight  pain  at  seat  of  operation.  No  tympanites  nor 
abdominal  tenderness. 

November.  28.  Patient  expresses  herself  as  feeling  very  well. 
At  no  time  since  the  operation  has  patient's  temperature  exceeded 
100.5°  F.  She  is  allowed  to  take  a  quantity  of  liquid  nourishment^ 
but  not  sufficient  to  satisfy  the  appetite.  I  consider  her  now  out 
of  danger.  Dr.  Hoelscher  is  to  be  congratulated  on  his  diagnosis 
in  this  case  in  the  absence  of  so  many  important  S3'mptoms. 

August  20,  1893.  Dr.  Hoelscher  reports  to  me  that  this 
patient  has  enjoyed  better  health  since  the  operation  than  she  had 
for  years  previous.     Not  one  of  the  symptoms  returned. 

Case  IV.     Mrs.  F- ,  Referred  to  me  by  Dr.  Hoelscher,  who 

furnished  me  the  following  history  : 

"Patient  age  fifty-six,  married,  has  several  children.  For  the 
last  four  years  has  suffered  from  attacks  of  difficult  breathing  and 
palpitation.     These    attacks    were    usually    accompanied    b}'  pain 


28 

and  tenderness  in  the  right  hypochondriac  region.  On  three 
or  four  occasions  in  the  past  year  has  had  colic,  and  most  of  that 
time  was  unable  to  work  and  was  confined  to  her  room.  These 
attacks  were  never  followed  by  jaundice,  or  vomiting.  Never  passed 
gallstones.  On  December  11,  1892,  patient  had  a  severe  attack 
of  pain  with  vomiting,  and  great  tenderness  on  pressure  in  the 
right  hypochondriac  region.  This  continued  up  to  the  time  of  the 
operation,  but  no  jaundice  was  present,  and  no  bile  in  the  urine." 
Dr.   Hoelscher    requested  the   operation  of    cholecystenterostomy. 

Operation  December  18,  1892.  Dr.  Murphy,  assisted  by  Drs, 
Hoelscher  and  Lee,  performed  cholecystenterostomy  by  means  of 
the  button.  A  number  of  gallstones  were  removed.  The  button 
was  easily  inserted.  The  abdominal  wound  dressed.  The  patient 
was  removed  from  the  table  in  excellent  condition.  Her  conva- 
lescence was  uneventful. 

August  20,  1893.  Patient  called  at  office  and  reported  that 
she  has  enjoyed  better  health  since  the  operation  than  for  years. 
Has  not  had  a  recurrence  of  the  dyspnoea  or  palpitation.  Has 
gained  very  much  in  weight  and  strength.     No  recurrence  of  pain. 

Case  V.      Mrs.  D.  W .,  Called  to  see  patient  by  Dr.  T.  J. 

Conley,  who  furnished  the  following  history:  "Patient,  widow,  age 
fifty-four.  Has  had  several  attacks  of  pain  in  the  right  hypochon- 
driac region  for  the  past  two  years.  Two  weeks  before  the  present 
attack  suffered  from  a  severe  purulent  bronchitis  and  was  much 
emaciated  by  it.  Shortl}^  after  the  bronchitis  subsided,  she  had  an 
attack  of  pain  and  pressure  in  the  right  hypochondriac  region.  She 
never  had  an  attack  of  jaundice. 

*'0n  examination  January  29, 1893,  patient  emaciated;  suffering 
from  bronchitis,  pain  and  tenderness  in  the  right  hypochondriac 
region;  a  small  tumor  can  be  felt  in  the  same  region.  It  is 
movable  and  can  be  separated  from  the  kidney." 

Operation  January  31,  1893.  Dr.  Murphy,  assisted  b}'  Drs. 
Conley,  Lee,  Hartmann  and  Wittwer,  performed  cholecj'sten- 
terostomy.  There  was  no  difficulty  in  inserting  the  button. 
Time  nineteen  minutes.  The  patient  suffered  very  much  from 
vomiting  for  five  days  following  the  operation.  Button  passed  on 
the  twenty-eighth  day  after  the  operation;  two  stones  were  also 
passed.  Highest  temperature  after  operation  100. 5°F.  This  was 
attributed  to  the  bronchitis. 

Dr.  Conley,  under  date  of  May  8,  1893,  wrote  me  the  follow- 
ing: 

"Mrs.  D.  W.,  on  whom  you  performed  cholecystenterostomy. 


29 

is  strong  and  enjoying  very  good  health.  Several  times  within  the 
last  two  weeks  she  has  walked  two  miles  without  fatigue,  'iliere 
is  no  tenderness  or  pain  at  the  seat  of  the  operation." 

Case  VI.  History  and  particulars  furnished  by  Dr.  E.  W. 
Lee,  in  whose  practice  this  case  occurred.  "Mrs.  L ,  age  forty- 
eight,  married.  At  intervals  in  the  last  three  years  patient  has 
suffered  from  severe  attacks  of  colic,  accompanied  by  nausea  and 
often  vomiting.  The  pain  was  always  located  in  the  right  hypo- 
chondriac region  and  often  in  the  'pit  of  the  stomach.'  These  at- 
tacks would  last  for  several  hours,  and  then  would  suddenly  disap- 
pear, leaving  a  soreness  at  the  seat  of  pain.  They  were  never  ac- 
companied by  jaundice  until  the  present  attack,  which  began  Feb- 
ruary 14,  1893,  six  days  before  operation.  This  attack  was  more 
severe  and  prolonged  than  any  of  the  previous  ones.  The  vomit- 
ing was  very  severe.  The  tenderness  over  the  gall  bladder  was  ex- 
treme. 

•'Operation  February  20,  1893.  Dr.  E.  W.  Lee,  assisted  by 
Drs.  Murphy,  Hartmann  and  Wittwer,  performed  cholecystenter- 
ostomy  by  means  of  the  button.  The  gall  bladder  was  very  i]iuch 
contracted,  and  there  were  many  adhesions.  The  adhesions  were 
separated  and  a  medium  sized  button  inserted,  producing  a  perfect 
approximation.  Seven  small  stones  were  removed  at  the  time  of 
the  operation.  The  recovery  was  uneventful.  Patient  passed  the 
button  March  6,  fourteen  days  after  the  operation.  A  number  of 
small  stones  were  passed  subsequently. 

"August  26,  1893.  Patient  has  been  able  to  work  more  since 
the  operation  than  for  three  years  previous.  Has  had  no  colic  or 
digestive  disturbances." 

Case  VH.      Dr.  William  J.  Mayo,  Rochester,  Minnesota,  in  a 

personal    letter  furnished  me  the  following  history:      "W.   H , 

Racine,  Minn.,  American,  male,  aet.  71.  Patient  gave  a  history  of 
colics  for  two  years,  jaundice  for  two  months;  great  debility,, 
cholemia,  white  stools,  etc. 

"Operation  April  6,  1893,  by  Dr.  W.  J.  Mayo,  assisted  by  Drs. 
C.  H.  Mayo  and  S.  Plummer.  Usual  incision  for  operation  on  gall 
bladder.  No  stone  found  in  gall  bladder;  obstruction  in  common 
duct.  Cholecystenterostomy  by  Murphy  button.  Bladder  could 
not  be  brought  to  surface,  obstruction  could  not  be  removed  ;  the 
button  was  readily  placed  in  position;  no  unpleasant  S5'mptoms 
since  the  operation." 

This  is  a  remarkable  case  on  account  of  the  age  of  the  patient. 


30 

and  the  doctor  deserves  great  credit  for  operating  on  a  patient  so 
debilitated  at  the  time  of  the  operation. 

Case  VIII.    From  Dr.  Wm.  D.  Foster,  Kansas  City,  Mo.  "Mrs. 

A.  M.  S ,  aet.    58.     Diagnosis,  cholelithiasis.      Operation   Nov. 

123,  1893,  cholecystostomy.  Gall  bladder  contained  more  than  one 
pint  of  fluid  consisting  of  mucus  and  bile  ;  six  hundred  and 
twenty-six  gallstones  removed  which  weighed  six  drachms. 
Gall  bladder  was  sutured  to  abdominal  wall  :  subsequently  the 
fistula  was  closed  with  wire  sutures;   operation  unsuccessful. 

"Operation  April  28,  1893,  cholecystoduodenostomy  by  means 
of  the  Murphy  button.  No  attempt  was  made  at  the  time  to  close 
the  fistula. 

"Aug.  13,  the  fistula  completely  closed  without  operation. 
The  bile  discharged  into  the  intestine." 

Case  IX.     M.  D ,  Alexian  Brothers  Hospital.    Transferred 

to  m}^  service  by  Dr.  Hoelscher.  Age  42,  male,  single.  Several 
weeks  ago  he  began  to  have  pain  and  a  sense  of  pressure  under 
the  border  of  the  right  ribs.  This  was  sometimes  accompanied  by 
severe  pain,  with  nausea  and  vomiting,  but  no  jaundice.  One 
week  ago  the  pain  became  very  much  more  severe,  and  was  soon 
followed  by  jaundice.  Shortly  after  the  jaimdice  appeared  the  pain 
ceased,  but  the  tenderness  remained  over  the  region  of  the  gall 
bladder. 

Siatus  praesens.  Icterus  very  marked,  large  quantities  of  bile 
in  the  urine,  feces  acholic.  Tongue  dry  and  brown;  temperature 
100. 4°F;  pulse  86,  full  and  regular.  The  patient  very  tender  over 
the  lower  margin  of  the  right  costal  arch.  An  induration  could  be 
felt,  but  the  gall  bladder  could  not  be  outlined. 

Diagnosis:      Cholelithiasis     with      occlusion    of     choledochus. 

Operation  May  6,  1893.  The  patient  acted  very  badly  under 
chloroform,  so  it  took  ten  minutes  to  open  the  peritoneal  cavity.  The 
gall  bladder  was  aspirated  and  joined  to  the  duodenum  with  the  but - 
ton  in  ten  minutes,  and  ten  minutes  was  consumed  in  making  the  toi- 
let and  suturing  the  wound,  making  thirty  minutes  in  all.  A  small 
stone  was  removed  from  the  gall  bladder,  but  the  obstruction  in  the 
common  duct  was  not  disturbed.  The  patient  made  an  uneventful 
and  rapid  recovery.  The  jaundice  rapidl}^  disappeared  after  the 
operation.  The  patient  was  up  and  about  the  ward  on  the  fif- 
teenth day.  Voided  the  button  on  May  22,  sixteen  days  after  the 
operation.      The  urine  showed  a  negative   reaction  for  bile  May  14. 

August   15,  1893.      The  patient  reported  at  the  hospital.     Has 


31 

gained  very  much  in  weight  and  is  enjoying  excellent  health.  No 
return  of    his  symptoms. 

Case  X.    Mrs.  B ,  Rock  Island,  111.,  admitted  to  St.  Joseph's 

Hospital,  May  13,  1893.  Patient  was  very  much  emaciated  from 
an  illness  extending  over  a  period  of  six  weeks.  In  the  last  two 
years  suffered  from  frequent  attacks  of  pain  in  the  right  hypochon- 
driac region,  accompanied  by  vomiting.  These  attacks  were  not 
followed  by  jaundice,  except  the  last  one,  which  began  six  weeks 
ago.  This  attack  continued  with  severe  pain,  vomiting,  great  ten- 
derness over  the  region  of  the  gall  bladder.  The  temperature  was 
of  an  intermittent  character,  fluctuating  every  other  day  from 
99°  F.  to  103°  F.  On  the  intervening  day  no  temperature.  The 
elevation  of  temperature  was  frequently,  but  not  always,  preceded 
by  a  chill. 

Status  firaesens.  Patient  slightly  icteric,  very  much  emaciated, 
pulse  120,  feeble  but  regular.  Urine  contains  a  considerable 
quantity  of  bile;  patient  is  nauseated  when  she  sits  upright.  The 
attacks  of  pain  come  on  every  few  hours  and  are  of  a  distinct 
colicky  character.  There  is  present  a  tumor  extending  three  inches 
below  the  margin  of  the  ribs  in  the  right  hypochondriac  region, 
and  about  three  inches  in  diameter;  it  moves  synchronously  with 
the  diaphragm  in  the  respiratory  act,  and  is  very  sensitive  on  pres- 
sure. It  can  be  separated  from  the  kidney,  which  is  situated  below 
and  behind,  and  does  not  move  with  respiration. 

Diagnosis:  Cholecystitis — impaction  in  the  ductus  chole- 
dochus. 

Operation  May  22,  1893,  Dr.  J.  B.  Murphy  assisted  by  Drs. 
Lee,  Hartmann  and  Wittwer.  Cholecystenterostomy  by  means  of 
anastomosis  button.  The  operation  was  performed  without  diffi- 
culty; time,  13  minutes.  A  few  calculi  were  removed  at  the 
time  of  the  operation. 

Subsequent  History.  There  were  no  unpleasant  symptoms  in 
the  subsequent  course  of  the  case;  patient  was  discharged  from 
the  hospital  on  the  fourteenth  day  after  the  operation.  Button 
passed  eighteen  days  after  operation. 

August  27,  1893.  Patient  has  increased  very  much  in  weight, 
is  enjoying  excellent  health,  attending  to  all  her  household  duties, 
and  has  had  no  return  of  the  symptoms. 

Case  XI.  Dr.  A.  H.  Fabrique,  of  Wichita,  Kansas,  in  a  per- 
sonal letter,  under  date  of  July  20,  1893,  writes  the  following: 

"Enclosed  please  find  report  of  patient  on  whom  I  performed 
cholecystenterostomy  by  means  of  your  button. 


32 

"Mr.  R ,  aet.  thirty-eight,  farmer,  weight  ISO  pounds.    Had 

been  subject  to  attacks  of  hepatic  colic.  Came  under  my  obser- 
vation about  the  middle  of  May,  1803.  Had  been  suffering  for 
two  weeks  previous  to  that  time  with  severe  pain  in  the  region 
of  the  liver,  for  which  he  was  taking  one-third  grain  of  morphine 
three  to  six  times  a  da}'.  Jaundice  all  over  the  body  for  a  whole 
week  prior  to  the  time  he  consulted  me. 

'•Operation,  June  1, 1893.  Found  the  wall  of  the  gall  bladder  so 
thickened  that  it  was  difficult  to  fasten  the  button  into  the  bladder. 
I  used  the  smallest  button;  duration  of  operation  thirty-five  min- 
utes. Closed  the  opening  with  silk  sutures  through  the  entire 
abdominal  wall.  Temperature  did  not  rise  any  time  above  99.5°F. 
Union  per  primam.  There  was  marked  improvement  on  the  third 
day;  skin  commenced  to  clear  up;  no  hepatic  pain  after  the  opera- 
tion. Stools  changed  from  white  to  a  natural  color;  button  passed 
on  the  twenty-first  day.  At  the  present  time  the  man  is  perfectly 
well,  pursuing  his  usual  avocation." 

Case  XH.  Under  date  of  July  20,  1893,  Dr.  W.  B.  Rogers,  of 
Memphis,  Tenn.,  states  that  immediately  after  his  return  from  the 
National  Association  of  Railway  Surgeons  at  Omaha,  he  had  an 
opportunity  to  use  the  button  in  the  operation  of  cholecystenteros- 
tomy. 

The  following  is  a  report   of  the  case   as  furnished  me  by  Dr. 

Rogers:     "W.   A.  E ,  male,  fifty-eight  years  of  age.     Presented 

April,  1893,  all  the.  physical  signs  of  an  enlarged  liver;  area  of 
dulness  occupying  the  epigastrium.  No  bile  in  the  stools.  Icterus 
marked;  emaciation  very  pronounced;  temperature  98°F.;  pulse  68. 
Diagnosis:  'Cancer  of  liver,'  had  been  repeated  by  several  physicians 
and  case  pronounced  hopeless.  The  enlargement  of  the  liver  was  of 
only  a  few  months' duration.  The  extreme  rapidity  of  growth  aroused 
suspicion  of  nonmalignancy.  Exploratory  incision  revealed  distend- 
ed gall  bladder.  Eighteen  ounces  of  mucopurulent  bile;  occlusion 
common  duct,  with  consequent  retention  and  congestion  of  liver.  No 
evidence  of  malignant  disease  could  be  detected;  nor  could  a  cal- 
culus be  detected  in  common  duct.  Cause  of  obstruction  not  dis- 
cerned. Patient's  condition  urged  a  rapid  completion  of  all  opera- 
tive procedures,  hence  fistula  was  established.  Patient  recovered 
from  operation.  Fistula  discharged  at  least  two  pints  of  bile  per 
day;  icterus  disappeared.  General  condition  continued  bad.  Ab- 
sence of   bile   in    bowel    kept    nutrition    below    par. 

"Operation,  June  1,  1893.  I  reopened  abdomen  and  united  small 
intestine  to  gall  bladder  by  means   of  Murphy's   button;    did    not 


33 

attempt  to  close  the  fistula;  tied  thread  to  the  button,  and  on  the 
tenth  day  removed  the  button  through  the  fistula.  No  reactionary 
fever  nor  bad  symptoms  other  than  that  of  depression  due  to 
shock.  Patient  gradually  improved,  and  at  the  end  of  eight 
weeks  was  able  to  be  up  and  about  the  house  gradually  gaining 
strength.  '  Fistula  has  contracted,  so  that  dressings  only  need 
changing  every  third  day.  Stool  contains  bile;  appetite  and  diges- 
tion steadily  growing  better,  and  evident  gain  of  fiesh.  I  found 
the  application  of  the  button  quite  readily  accomplished;  the 
coaptation  of  parts  perfect,  and  the  results  are  as  stated." 

Case  XIII.     This  case  occurred  in  the  practice  of  Dr.  F.  S. 

Hartmann  who  furnished  the  following  report :     "M.  McC ,  age 

60,  widow,  multipara.  About  eight  years  ago  she  had  a  severe 
attack  of  colicky  pain  in  right  hypochondriac  region  ;  pain  was 
intense  and  lasted  about  three  days.  Patient  was  jaundiced  during 
this  attack  ;  she  does  not  remember  any  other  symptoms. 

"In  March,  1893,  she  had  a  second  attack,  colicky  pains 
in  hepatic  region  and  epigastrium,  vomiting,  chills,  fever,  jaun- 
dice ;  sick  about  one  week.  Patient  came  from  Philadelphia  to 
Chicago  on  a  visit  last  April ;  since  her  arrival  she  has  had  nearly 
a  dozen  attacks  of  pain  which  would  last  from  six  to  twelve  hours, 
and  have  always  been  followed  by  great  prostration.  The  last 
attack  began  at  1  A.  M.  July  13,  1893;  colicky  pains,  great  tender- 
ness over  upper  half  of  abdomen,  more  marked  in  region  of 
gall  bladder;  jaundice,  persistent  vomiting,  temperature  100°-101°F,^ 
bile  in  urine,  clay  colored  passages. 

"Operation,  July  18,  1893.  Cholecystenterostomy  with  Murphy 
button,  performed  by  Dr.  F.  S.  Hartmann,  assisted  by  Drs.  Mur- 
phy, Lee  and  Wittvver;  time  seventeen  minutes.  After  operation 
patient's  condition  was  excellent,  and  her  recovery  was  uninter- 
rupted. Pulse  always  below  100  and  good;  temperature  never  ran 
above  99.8°F.,  and  attacks  of  colicky  pain  ceased.  Vomited  once  or 
twice  daily  for  three  days;  vomited  matter  containing  bile.  Forty- 
eight  hours  after  operation  gauze  drain  was  removed  from  perito- 
neal cavity.  Bile  gradually  disappeared  from  urine,  and  feces 
regained  their  color.  At  no  time  was  there  any  great  tenderness 
in  region  of  operation.  Button  and  fourteen  calculi  were  passed 
in  one  stool  on  the  fourteenth  day  after  operation.  Greatest  cir- 
cumference of  largest  calculus  2i|in;  smallest  circumference  of 
largest  calculus  2\^  in;  circumference  of  button  2i|- in.  Patient 
sat  up  on  the  nineteenth  day  after  the  operation. 


/ 

/ 


34 

•  "August  29,  1893.  Patient  enjoying  excellent  health,  better 
than  at  any  time  since  her  second  attack  of  colic." 

Case  XIV.  In  a  personal  letter  to  me,  Dr.  Alex.  Hugh  Fer- 
guson, of  Winnepeg,  Manitoba,  under  date  of  August  14,  writes  the 
following: 

"Operation,  August  3,  1893,  I  used  your  button  in  uniting  the 
gall  bladder  with  the  duodenum — cholecystoduodenostomy.  Patient 
passed  the  button  on  the  eleventh  day,  and  her  condition  is  excel- 
lent. The  case  was  difficult  to  manipulate  owing  to  the  short 
build  and  large  amount  of  fat  (fully  three  inches)  in  the  abdominal 
wall.  It  was  a  case  of  dropsy  of  the  gall  bladder.  One  stone  was 
removed  from  it,  another  was  felt  to  occlude  the  duct." 

August  28,  1893,  I  received  a  report  of  this  case  through  Dr. 
McArthur,  of  Winnepeg,  who  had  assisted  Dr.  Ferguson  at  the 
operation;  he  states  that  the  patient  is  in  excellent  health,  and 
that  Dr.  Ferguson  expressed  himself  concerning  the  button  in  the 
following  words:  *'It  is  the  greatest  innovation  in  abdominal  sur- 
gery since  that  of  antisepsis." 

Case  XV.  From  Dr.  T.  D.  Lane,  Media,  Pa.  ''Mrs.  L ,  aet. 

forty-five,  married,  one  child.  In  October  1892,  was  taken  ill  with 
intense  abdominal  pain,  paroxysmal  in  character,  accompanied  by 
vomiting  and  constipation.  Jaundice  appeared  on  second  day, 
also  bile  in  urine;  stools  acholic;  on  sixth  day  severe  chill  fol- 
lowed b}^  temperature  of  104°  F.  As  the  jaundice  was  of  the  most 
marked  type,  coming  on  suddenly  with  no  previous  history  of 
trouble  or  emaciation,  vomiting  or  pain  and  the  temperature  and 
chills  persisting  for  several  days,  I  sent  the  woman  to  the  Jeffer- 
son Hospital  under  the  care  of  Prof.  I.  C.  Wilson  with  the  diag- 
noses of  acute  obstructive  jaundice  and  Charcot's  hepatic  fever, 
with  the  hope  that  an  early  operation  at  least  of  an  exploratory 
character  would  be  performed.  She  remained  in  the  hospital  nine- 
teen weeks.  The  chills  and  jaundice  persisted;  she  emaciated 
rapidly;  she  was  seen  in  consultation  by  Drs.  Keen  and  Brinton. 
Operation  was  deferred  on  account  of  the  woman's  weak  condi- 
tion and  the  possibility  of  malignant  character  of  the  obstruction. 
The  fever  and  jaundice  finally  disappeared  and  she  was  discharged 
from  the  hospital  February  1,  1893.  She  gained  rapidly  until  July 
15,  when  I  was  called  to  see  her  again.  The  vomiting,  chills  and 
fever  had  suddenly  returned.  I  determined  to  perform  cholecys- 
tostomy  at  once.  This  I  was  able  to  do  without  much  trouble  in 
an  operation  of  one  sitting.  I  removed  a  verj^  large  stone  marked 
with  numerous  facets.    I  could  not  discover  the  presence  of  anoth- 


35 

er  in  the  common  duct  with  my  finger  through  the  foramen  of 
Winslow.  Supposed  the  obstruction  was  due  to  cicatricial  contrac- 
tion. Temperature  dropped  to  normal  the  following  day.  In  a 
month  she  was  up  and  about.  Still  the  stools  remained  clay 
colored  and  she  suffered  much  from  gaseous  distention  of  the 
bowels.  She  was  also  greatly  annoyed  by  the  voluminous  dis- 
charge of  the  bile  upon  the  surface.  I  determined  to  close  the  bil- 
iary fistula. 

"  Operation,  September  20,  1893.  I  made  a  Y-shaped  in- 
cision over  the  old  cicatrix,  pushed  the  great  omentum  aside  and 
drew  out  a  small  knuckle  of  intestine  and  performed  cholecystenter- 
ostomy,  using  the  smallest  sized  Murphy  button.  The  fistulous 
tract  was  curetted  and  closed  at  once  with  a  circular  stitch.  The 
abdominal  wound  was  closed  without  drainage.  The  temperature 
remained  between  99^°  and  100^°  F.  for  several  days.  Otherwise 
she  made  an  uninterrupted  recovery.  On  the  fifteenth  day  the  but- 
ton was  found  in  the  stool.  Since  then  she  has  been  in  very  good 
health,  able  to  attend  to  all  her  duties  and  has  gained  twelve 
pounds  in  weight." 

Case  XVI.  Report  of  operation  given  by  Dr.  J.  Frank  in 
whose  service  at  St.  Elizabeth's  Hospital  the  case  occurred.  "Pa- 
tient admitted  at  Hospital  as  a  '  Perityphlitic  Abscess.'  Careful 
examination  showed  that  it  was  a  very  much  distended  gall  blad- 
der. An  incision  was  made  directly  over  the  tumor.  The  gall 
bladder  was  found  adherent  and  was  immediatel}^  incised;  143 
stones  were  extracted,  and  the  opening  allowed  to  remain.  Pa- 
tient was  discharged  with  a  fistula.  Returned  several  months 
after  with  a  large  quantity  of  bile  discharging  from  fistula,  probed 
and  found  stone;  removed.  The  canal  leading  to  bowel  could  not 
be  entered.  The  discharge  continued  in  large  quantity  and  the 
patient  was  losing  strength.  It  was  decided  to  perform  a 
cholecystenterostomy  to  allow  the  secretion  to  enter  the  bowel  in 
large  quantity. 

"Operation  Oct.  20,  1893  by  Dr.  M.  H.  Luken.  An  incision  was 
made  at  the  side  of  the  fistula.  The  gall  bladder  which  at  the  time 
of  the  first  operation,  was  a  large  distended  sac,  had  now,  four 
months  later,  contracted  to  a  tube  not  much  larger  than  a  finger 
and  was  adherent  to  the  surrounding  tissues.  It  was  difficult  to 
expose  a  sufficient  surface  of  the  gall  bladder  to  insert  a  button. 
The  button  was  finally  placed  in  position  and  the  duodenum  united 
to  the  gall  bladder.  The  button  passed  on  the  13th  day  without 
pain.     An  operation  has    not  yet  been    performed  to  close  the  ex- 


36 

ternal  fistula.  A  patulous  opening  now  exists  between  the  gall 
tracts  and  duodenum." 

The  difficult}^  of  performing  the  operation  of  cholecystenteros- 
tomy  under  these  conditions  was  extremely  great  and  as  Dr.  Frank 
expresses  it  "I  do  not  think  that  the  operation  could  have  been 
performed  by  any  other  means  than  the  button." 

Case  XVII.  Dr.  F.  S.  Hartmann  furnished  me  with  the  re- 
port of  this  case  that  occurred  in  his  practice.  "Patient  states  that 
about  five  years  ago  he  had  an  attack  of  painful  stomach  trouble;  it 
was  not  accompanied  by  nausea  or  vomiting.  The  illness  lasted  about 
one  week.  On  August  23,  1893,  patient  experienced  a  dull  aching 
pain  in  pit  of  stomach  which  lasted  two  days  ;  then  suddenly  be- 
came much  worse  and  of  a  colicky  nature  and  was  accompanied  by 
persistent  vomiting  of  bile  and  mucus.  The  colicky  pain  lasted 
two  days  and  was  very  intense.  The  patient  has  had  eight  similar 
attacks  since.  A  characteristic  feature  of  all  his  attacks  has  been 
the  peculiar  manner  in  which  three  symptoms  have  followed  each 
other : 

"First,  acute  colicky  pain; 

"Second,  a  burning  sensation  in  chest  and  throat; 

"Third,  persistent  vomiting. 

"He  suffered  from  digestive  disturbances  for  fifteen  years. 
During  an  attack  occurring  September  29,  a  trace  of  bile  was  found 
in  urine.  Patient  was  never  jaundiced.  No  calculi  were  ever  found 
after  an  attack.      Diagnosis,  cholelithiasis,  obstruction  of  cysticus. 

"Operation  October  26,  1893,  by  Dr.  F.  S.  Hartmann,  assisted 
by  Drs.  Murphy,  Wittwer  and  Lee.  Cholecystenterostomy  by  means 
of  Murphy  button.  Gall  bladder  somewhat  enlarged.  Time  for 
insertion  of  button  seven  and  one-half  minutes.  Time  for  entire 
operation,  twenty-six  minutes.  Convalescence  uneventful.  Button 
passed  on  ninth  day." 

Case  XVIII.    W.  B ,  aged  forty  years,  cigar  maker.    Three 

years  ago  had  first  typical  attack  of  gallstone  obstruction,  accom- 
panied by  jaundice.  Since  that  time  has  had  five  similar  attacks;  last 
one  began  about  two  weeks  ago;  was  less  severe  than  previous  at- 
tacks. 

Operation  November  7,  1893,  by  Dr.  Murphy.  Cholecystenter- 
ostomy by  means  of  anastomosis  button,  smallest  size.  Gall  blad- 
der was  found  distended;  gallstones  not  removed.  Time  from  be- 
ginning of  operation  to  completion  of  anastomosis  eleven  minutes. 
Patient  acted  very  badly  under  anesthetic;  ether.  Had  some 
bronchitis  following  operation;  aside  from  this  his  convalescence 


3  7 

was  uneventful.  Was  about  the  ward  in  three  weeks.  Jaundice 
had  completely  disappeared. 

Case  XIX.      By  Dr.  James  H.  Dunn,  Minneapolis,  Minnesota. 

"  Mrs.  W ,  age  thirty  seven,  suffered  from   attacks  of  gall  colic 

every  three  or  four  months  for  the  past  four  years.  They  were 
accompanied  by  vomiting,  jaundice,  constipation,  clay  colored 
stools.  The  last  attack  has  continued  for  about  eight  weeks, 
necessitating  the  use  of  large  doses  of  morphine  all  the  time. 

"Operation  January  6,  1894.  Median  incision,  found  the  gall 
bladder  normal  size,  and  nearly  full  of  stones,  duct  impacted  with 
small  ones.  Cholecystoduodenostomy  with  the  Murphy  button; 
patient's  only  complaint  after  operation  was  pain  on  deep  inspira- 
tion, temperature  reached  100°F.  once;  button  passed  on  the  eigh- 
teenth day,  and  with  it  twenty-six  stones.  Patient  made  an  une- 
ventful recovery. 

"In  these  days  it  is  pretty  hard  to  say  where  we  are  in  surgery 
but  I  arfi  very  sure  the  Murphy  button  has  come  to  stay." 

Case  XX.  Case  referred  to  me  by  Dr.  J.  H.  Hoelscher,  who 
had  made  the  diagnosis  of  cholelithiasis.  Mrs.  F.  H ,  age  thirty- 
six;  married;  two  children;  has  been  sick  for  twelve  years;  has 
had  attacks  of  colic  every  two  or  three  months  in  that  time,  not 
always  accompanied  by  vomiting,  never  by  a  typical  jaundice 
although  occasionally  there  has  been  a  slight  icteric  discoloration 
of    the  skin,  great  digestive  disturbance,  no  tumor  to  be  felt. 

Operation  February  13,  1894,  by  Dr.  J.  B.  Murphy.  Incision 
from  ninth  costal  cartilage;  gall  bladder  adherent  to  duodenum, 
liberated,  brought  into  wound,  puckering  string  placed  in  position, 
incised,  and  two  stones  three-fourths  of  an  inch  in  diameter  re- 
moved, some  viscid  mucus  but  no  bile  escaped,  button  placed  in 
position  in  gall  bladder  and  duodenum,  and  closed  ;  no  drainage. 
Time  of  operation,  eleven  minutes,  convalescence  uneventful, 
patient  did  not  even  vomit  from  the  anesthetic,  and  temperature 
did  not  exceed  99°F. 

VIII.  Cholecystectomy,  Total  Extirpation  of  the  Gall  Bladder. — 
This  operation  was  introduced  by  Dr.  Langenbuch.  At  first  there 
was  most  bitter  opposition  to  the  operation,  but  it  has  now  obtained 
great  recognition.  For  a  certain  class  of  cases  it  is  the  operation 
par  excellence:  1,  on  account  of  its  safety;  2,  because  it  completely 
fulfils  the  indications.  Langenbuch  is  sustained  in  the  theory  of 
his  operations  by  the  fact  already  mentioned,  namely  : 

Absence  of  the  gall  bladder  being  harmless,  as  far  as  the 
health  of  the   patient  is  concerned,  as   demonstrated   by  the  large 


38 

number  of  animals  and  men  in  which  this  viscus  has  been  found  to 
be  congenitally  absent,  and  made  no  apparent  difference  in  their 
health.  I  have  found  in  dogs,  on  which  I  have  performed  this 
operation,  that  their  health  was  not  interfered  with  in  the 
slightest. 

The  onl}'  question  of  gravit}'  for  the  consideration  of  the  sur- 
geon, as  long  as  its  absence  does  not  materially  affect  the  patient^ 
is  :  What  are  the  dangers  of  the  operative  procedure  itself?  That 
these  dangers  are  not  great  is  shown  by  the  following  statistics  : 
We  have  collected  in  all  sixty-five  cases;  there  were  eleven  deaths, 
a  mortality  of  seventeen  per  cent,  which  is  even  more  favorable 
than  cholecystostomy,  and  this  operation  is  rapidly  finding  favor 
with  surgeons,  notwithstanding  the  assertions  of  Tait  when  the 
operation  was  first  suggested  in  May,  1884,  that  it  was  "absurd;"  in 
June,  1885,  that  it  was  "radically  absurd,"  and  in  October,  1889, 
that  it  was  "intrinsically  absurd,"  (Courvoisier);  another  illustra- 
tion of  how  valueless  a  man's  opinion  may  be  of  an  operation  that 
he  has  not  tried.  The  indications  for  this  operation  are  :  1,^ 
hydrops  and  empyema  of  the  gall  bladder  when  it  is  already  dis- 
connected from  the  choledochus  by  occlusion  of  the  ductus  cysti- 
cus  ;  2,  in  severe  chronic  recurrent  cholelithiasis  vesicularis  ;  3,  in 
severe  diseases  of  the  wall  of  the  gall  bladder  itself,  ulceration, 
gangrene,  contraction  and  carcinoma ;  4,  in  internal  rupture  or 
wounding  of  the  gall  bladder  when  suture  is  difficult  or  impossible. 
It  is  contraindicated  by  strong  adhesions  to  its  surroundings  ;  by 
broad  and  close  attachments  to  the  liver ;  in  all  permanent 
closures  of  the  choledochus. 

IX.  CholedochoUthotripsy ,  or  Crushing  of  Gall  Stone  in  the 
Choledochus. — The  operation  has  been  performed  three  times  with 
success,  by  Crede,  Courvoisier  and  Kocher.  It  was  found  in  these 
cases  that  there  were  fragments  after  the  crushing  that  would  not 
pass  through  the  choledochus  but  might  regurgitate  back  into  the 
gall  bladder.  There  is  also  no  certainty  that  the  remainder  of  the 
canal  is  patulous  below  the  point  where  the  fragments  lodged. 
Crede's  patient  had  severe  attacks  of  colic  and  fever  in  passing 
the  fragments.  Again,  there  is  danger  in  the  act  of  crushing  the 
stones  of  injuring  the  walls  of  the  duct  so  as  to  subsequently 
cause  a  perforation;  for  these  reasons  this  operation  should  not  be 
performed. 

X.  Choledocholithcctotny,  with  subsequent  suture  of  duct. — 
This  operation  has  been  performed  five  times  with  two  deaths, 
giving  a  mortality  of    forty  per   cent.      It  is  a  very  difficult  opera- 


39 

tion  to  perform  as  the  duct  is  deeply  seated  and  the  escape  of  bile 
in  the  field  of  operation  after  the  incision  is  very  annoying  to  the 
operator.  This  operation  was  first  performed  by  Courvoisier,  and 
he  deserves  great  credit  for  his  ingenuity  and  courage  in  devising 
and  undertaking  this  operation,  as  well  as  being  the  first  to  per- 
form a  successful  cholecystendysis,  and  to  do  the  first  successful 
choledocholithotripsy. 

This  operation  is  to  be  undertaken,  1,  Where  the  stone  is  l^rge 
and  firmly  impacted  in  the  duct  and  when  the  patient  has  symptoms 
of  intermittent  fever  and  chills.  2,  Where  the  stone  is  impacted 
in  the  duct  and  the  ductus  cysticus  is  obliterated,  preventing  the 
formation  of  a  gall  bladder  and  intestinal  fistula  for  the  escape  of 
the  bile.  3,  Where  it  has  produced  ulcerative  perforation  and 
the  wall  at  the  opening  is  in  a  healthy  condition,  otherwise  the  gall 
duct  should  be  excised  at  that  point,  both  ends  ligated  and  a  chole- 
cystenterostomy  performed. 

The  following  operation  was  performed: 

Case  I.  Mrs.  Matilda  B ,  age  thirty-five,  multipara,  ad- 
mitted to  hospital  Sept.  20th,  1893.  Enjoyed  perfect  health  until 
three  years  ago,  at  that  time  had  first  attack  of  colic,  intense  pain 
of  sudden  origin  in  right  hypochondriac  region,  very  sensitive 
under  right  costal  cartilage,  pain  continued  several  hours,  followed 
by  vomiting;  was  not  followed  by  jaundice.  Two  years  later  sim- 
ilar attack  with  no  jaundice.  Five  weeks  ago  had  third  attack. 
Has  had  frequent  severe  attacks  of  pain  since  the  beginning  of  the 
last  one  a  week  ago,  which  have  continued  to  the  present  time, 
October  20,  1893.  Jaundice  made  its  appearance  for  the  first  time 
four  weeks  before  admission,  and  is  still  present.  She  does  not 
know  that  she  ever  passed  a  gall  stone.  Never  had  any  urinary 
difficulty.  Stomach  always  good.  Was  never  free  from  tenderness 
in  right  epigastric  region  since  time  of  first  attack.  Present  con- 
dition; very  icteric,  rapid  feeble  pulse,  expression  of  severe  suf- 
fering, complains  of  great  thirst,  anorexia.  Very  sensitive  in  right 
hypochondriac  region.  No  tumor  perceptible.  Temperature,  103° 
F.;  pulse,  138;  respiration,  34.  Diagnosis:- — Hepatic  calculus  im- 
pacted in  ductus  choledochus.  October  21,  8  A.  M.,  pulse,  100; 
temperature,  102.8°  F.;  respiration,  36;  P.  M.  pulse,  102;  tempera- 
ture, 103°  F.;  respiration,  36.  October  22,  P.  j\I.  pulse,  96,  tem- 
perature 102°F. ;  respiration,  40.  October  23,  A.  M.,  pulse  94;  tem- 
perature 99°F.;  respiration,  30. 

Operation  October  23,  11  A.  M.  Dr.  Murph}^  assisted  by 
Drs.  Hartmann,  Wittwer,  Kortebein,  performed  laparotom_v:  found 


40 

gall  bladder  contracted  to  a  tube,  large  calculus  one-half  inch  in 
diameter  situated  in  the  middle  of  choledochus.  Gall  bladder 
could  not  be  utilized  for  approximation  to  the  intestine.  It  was 
decided  to  remove  the  calculus  from  the  common  duct,  which  was 
thoroughl}'  exposed.  An  incision  one-half  inch  long  was  made  in 
the  duct,  parallel  with  it,  stone  extracted.  The  opening  in  duct 
was  united  with  continous  suture.  Gauze  drainage.  Time  forty- 
five  minutes.  There  was  but  very  little  hemorrhage  during  opera- 
tion, and  none  whatever  after  suturing.  Some  shock.  Pulse, 
11:40  A.  M.,  immediately  after  operation,  64;  respiration  30;  5:30 
P.  M.  pulse  72;  temperature  9'7°F.;  respiration  32;  10  P,  M.  pulse 
18;   temperature  97. 4°F. ;  respiration  32. 

October  24,  8  A.  M.,  pulse  94;  temperature  98.8°F.;  respira- 
tion 32.  Rested  well  during  night;  nauseated,  but  no  vomiting 
since  operation.  October  24th,  6  P.  M.,  pulse  144;  temperature 
103°  F.;   respiration  36. 

October  24,  12  P.  M.,  pulse  108;  temperature  101°F;  respira- 
tion 26.     Condition  much  improved;   pulse  still  feeble. 

October  25,  2  A.  M.,  pulse  110;  temperature  102°  F.;  respir- 
ation 35.     Pulse  very  weak.     Died  at  3  A.  M.,  very  suddenl)'. 

Post-mortem  not  allowed.  It  is  therefore  impossible  to  say 
what  was  the  cause  of  death. 

The  clinical  cases  requiring  surgical  interference  in  lesions 
of  the  gall  tracts  are  the  following  : 

First,  in  all  cases  of  obstructive  jaundice,  where  the  jaundice 
exists  during  a  period  of  two  weeks. 

Second,  in  all  recurrent  cases  of  obstructive  jaundice. 

Third,  in  cases  of  recurrent  cholecystitis. 

Fourth,  in  recurrent  cases  of  colic  from  cystic  duct  obstruc- 
tion, alwa3's  without  jaundice. 

Fifth,  in  retention  cysts  of  gall  bladder. 

Sixth,  in  malignant  growths  of  gall  bladder. 

Contraction  of  the  gall  bladder  occurs  in  more  than  eight}^  per 
cent  of  the  cases  of  cholelithiasis.  It  is  the  result  of  the  cicatricial 
•contraction  produced  in  the  gall  bladder  bj'  a  chronic  inflamma- 
tion or  irritation  of  it  b}^  the  gallstones;  therefore  the  earlier  the 
operation  is  performed,  the  less  liable  we  are  to  find  contraction. 
There  is  another  danger  and  that  a  serious  one;  perforation  of  the 
tracts  by  the  calculus.  I  have  been  called  in  consultation  within 
the  last  eighteen  months  in  three  cases  of  perforation  of  the  gall 
tracts,  all  attended  by  an  infective  peritonitis  and  all  died;  a 
histor}'  of    repeated    attacks   was    given   in  each.      In    one  case  the 


41 

patient  had  the  question  of  operation  under  advisement  on  account 
of  the  frequency  of  attacks.  None  of  them  were  suffering  from 
colic  or  obstructive  jaundice  at  the  time  of  the  perforation,  which 
shows  that  there  is  danger  even  in  the  quiescent  stage. 

Another  reason  for  the  early  operation  is  the  danger  of  a 
malignant  growth  being  produced  by  the  constant  irritation. 
In  looking  over  the  records  of  the  pathological  institutes  we  find 
abundant  proof  that  a  considerable  percentage  of  cases  of  chole- 
lithiasis terminate  with  carcinoma  of  the  gall  tracts.  I  have  seen 
a  large  number  of  post-mortems  presenting  this  condition. 

These  reasons,  along  with  the  dangers  which  accompany  an 
acute  attack  of  obstructive  jaundice  are,  I  think,  considering  the 
small  percentage  of  mortality,  sufficient  to  justify  early  operative 
interference. 

You  will  find  in  reviewing  the  results  of  these  operations  that 
the  mortality  is  greatest  in  the  operation  of  cholecystenterostomy 
^'in  one  sitting,"  by  means  of  suture,  in  which  thirty-five  per 
•cent  of  the  cases  terminated  fatally.  The  operation  showing  the 
next  greatest  fatality  is  cholecystendysis,  with  a  mortality  of 
twenty-three  per  cent.  Next  high  in  the  scale  of  mortality 
is  cholecystostomy  "in  one  sitting,"  the  operation  which  is  most 
prevalent  and  performed  more  frequently  than  any  other,  and 
almost  as  frequently  as  all  the  others  combined;  its  mortality  is 
nineteen  per  cent.  This  great  mortality  should  cause  every 
thoughtful  operator  to  endeavor  to  find  some  other  means  whereby 
his  patients  will  not  be  jeopardized  to  such  a  great  degree,  and 
while  the  mortality  is  nineteen  per  cent,  the  percentage  of  perfect 
recoveries  is  only  about  fifty-one  per  cent ;  making  the  chances  for 
life  in  the  ratio  of  five  to  one,  and  the  chances  for  complete  recov- 
ery but  one  to  two.  Then  comes  cholecystectomy  with  a  mor- 
tality of  seventeen  per  cent.  The  most  favorable  of  the  older 
operations  is  cholecystostomy,  "in  two  sittings,"  in  which  you 
have  a  mortality  of  ten  per   cent. 

In  reference  to  the  criticisms  by  Prof.  Senn,  Jour.  Am.  Med. 
Ass'n.,  August  12,  1893,  I  would  say  that  while  he  does  not  com- 
ment on  the  use  of  the  "button  "  in  cholecystenterostom}',  some  of 
his  criticisms  would  be  applicable  to  the  use  of  the  button  in  that 
operation  as  well  as  operations  on  the  intestines,  therefore,  I  deem 
it  proper  to  treat  them  in  this  article. 

First,  he  says  that  "it  is  no  improvement  on  the  rings 
employed  by  Denans    more  than    half    a  century  ago."     The  cor- 


42 


rectness  of  this  statement  can  be  readih'  tested  by  a  cursory  com- 
parison of  the  two  devices,  (compare  figure  2  and  figure  6). 

Second,  he  says  "  that  a  foreign  body  is  left  in  the  intestinal 
canal,  which  may  become  a  source  of  danger  on  its  way  to  the 
distal  end  of  the  alimentary  canal."  Will  it  become  a  source  of 
danger,  and  when?  .The  ileocecal  valve  is  the  place  in  the  nor- 
mal intestinal  tract  in  which  it  would  be  most  likely,  if  at  all,  to 
produce  an  obstruction.  That  this  valve  in  its  normal  condition 
allows  the  passage  of  bodies  much  larger  in  diameter  than  the 
button,  is  shown  b}'  the  many  experiments  on  that  portion  of  the 
canal.  It  is  further  shown  by  the  clinical  observation  of  medical 
practitioners,  who  from  time  immemorial  have  seen  children 
swallow  coins,  nuts,  peach  stones,  marbles  and  other  foreign 
bodies  much  larger  in  proportion  to  the  child's  intestine  than 
the  button  recommended,  and  pass  them  without  producing 
unpleasant    symptoms.     This  is  considered  by  doctors  to  be  of  so 


Figure  6. — Denans'  Rings. 

little  danger  that  they  advise  the  patient  "to  pay  no  attention  to 
it,  and  forget  that  such  a  thing  occurred."  What  surgeon  would 
become  alarmed  if  one  of  his  young  patients  swallowed  a 
coin  or  marble?  Admit  that  a  coin  or  marble,  under  certain 
pathological  conditions,  has  produced  trouble;  to  the  one  such 
case  there  are  thousands  that  have  not. 

It  will  be  admitted  that  with  cicatricial  contraction  of  the 
bowel  or  a  malformation  of  the  ileocecal  valve,  obstruction  might 
be  produced  by  the  button,  but  the  proportion  of  these  cases  would 
be  about  the  same  as  the  proportion  of  cases  of  trouble  produced 
by  the  coin  or  marble,  and  so  small  as  to  be  scarcely  worth  serious 
attention. 

I  have  now  reports  of  three  hundred  (300)  operations  and 
experiments  with  the  button.  The  obstruction  so  much  dwelt  upon 
by  the  critics  of  the  button  did  not  occur  in  one  of  my  cases,  nor 
has  it  "come  to  my  knowledge"  that  it  occurred  even  once  in  the 
cases  of  others  who  have  performed  the  operation. 

Dr.  W.  W.  Keen  in  the  same  paper  from  which  Senn  quotes  a 
portion  of  a  sentence  referring    specifically  to  the  objection,  says^ 


43 

"on  the  whole,  however,  I  do  not  feel  that  this  objection  is  a  very- 
serious  one,  since  the  condition  requiring  the  use  of  the  buttons,  if 
they  be  used,  is  one  which  must  dominate  all  other  risks."  (Anfiah 
of  Surgery,  June,  1893,  p.  660).  It  can  therefore  be  seen  that  the 
danger  of  obstruction  by  the  button  is  so  slight  that  it  is  entitled 
to  no  weight  in  view  of  the  ease  with  which  it  is  inserted  and  the 
certainty  with  which  it  fulfils  its  purposes. 

Third.  "Any  instrument,  suture  or  ligature  used  in  effecting 
the  co.ntinuit}^  of  a  wounded  or  divided  bowel  that  produces  gan- 
grene must  be  looked  upon  as  a  source  of  danger."  The  term 
gangrene  is  misleading  in  this  connection;  the  term  in- 
tended, no  doubt,  was  pressure  atrophy.  Every  suture^ 
every  mechanical  means  that  is  used,  every  ligature  that  is  tied  in 
approximating  the  intestine  produces  pressure  atrophy  in  a  greater 
or  lesser  degree,  or  it  gives  no  support.  Shall  we  discard  all  these 
useful  measures?  Pressure  atrophy,  "gangrene,"  (Senn)  in  vas- 
cular tissues  is  limited  to  the  area  of  pressure  in  which  the  cir- 
culation is  shut  off  and  is  always  controlled  thereby. 

The  button  above  all  other  methods,  suture,  rubber  rings,  bone 
plates,  etc.,  protects  the  peritoneal  cavity.  There  is  no  suture  on 
the  peritoneal  surface;  there  is  nothing  left  within  the  peritoneal 
cavity;  it  is  shut  out  and  sealed  up  by  a  uniform  compress.  This 
compress  closes  as  pressure  atrophy  takes  place  and  closes  in  the 
direction  of  pressing  the  surfaces  desired  to  be  agglutinated,  closer 
and  closer  together.  This  is  not  accomplished  by  any  other  device- 
True  there  is  a  substance  in  the  caliber  of  the  intestine,  call  it  for- 
eign if  you  please;  so  are  the  materials  used  as  food  to  some  de- 
gree foreign  materials,  but  they,  like  the  button,  are  on  the  safe 
side  of  the  intestine  within  it,  not  without. 

Fourth.  "  Because  the  lumen  of  the  connecting  part  is  not  large 
enough  as  a  temporary  outlet  for  the  intestinal  contents  above  the 
seat  of  operation."  This  objection  is  not  tenable.  The  surgeon 
well  informed  on  the  physiology  of  the  small  intestine  knows  that 
its  contents  are  always  fluid,  except  in  cases  where  some  indiges- 
tible solid  substance  is  introduced.  Patients  are  not  usually 
allowed  an  ostrich  diet  for  a  few  days  following  an  intestinal  an- 
astomosis. No  matter  what  medicine  may  be  given,  it  does  not 
render  the  contents  of  the  small  intestine  solid;  they  are  alwa3^s 
fluid.  The  amount  of  fluid  that  would  pass  through  the  central 
opening  in  a  medium  sized  button  in  twenty-four  hours  can  be 
easily  computed,  and  represents    man)^  times    the    weight  of  the 


44 

entire  bod\',  while  the  average  amount  of  feces  in  the  same  time 
is  five   ounces. 

Fifth.  The  fragment  of  a  sentence  quoted  b}^  Senn,  from 
Keen's  article,  is  such  an  inadequate  representation  of  the  scien- 
tific and  fair  manner  in  which  this  recognized  authorit}^  treats 
the  subject,  that  I  venture  to  quote  more  extensively  from  it  as 
follows,  pages  660,  661:  "The  speed  and  certaint)^  with  which 
an  anastomosis  can  be  made  once  the  bowel  is  prepared  for  it,  are 
certainl}'  advantages  which  the  button  possesses  over  all  other 
means  of  anastomosis,  whether  by  simple  suturing  or  by  bone 
plates,  catgut  or  other  rings."  "  It  is  certainly  a  most  happy 
mechanical  invention,  especially  the  method  of  fastening  it  by 
what  is  practically  a  secure  screw,  and  3'et  instead  of  being  rotated 
in  order  to  fasten  it,  it  simpl}^  needs  to  be  pushed  home.  The 
two  projecting  teeth  which  answer  the  purpose  of  the  male  screw, 
make  it   one   of   the  most    ingenious   devices   I  have    ever    seen." 

From  Keen's  postscript  I  will  quote  the  following,  as 
showing  the  perfection  of  the  union:  "From  the  outside,  one  would 
almost  think  that  it  was  the  normal  termination  of  the  ileum  in  the 
colon;  no  more  perfect  union  could  be  imagined."  In  regard  to 
the  contraction  found  by  Keen  in  the  post-mortem  which  he 
reports,  we  are  compelled  to  admit  the  force  of  the  suggestion 
made  to  me  by  Dr.  W.  J.  Mayo,  that  a  vital  point  in  the  report  of 
that  post-mortem  is  omitted,  namely,  a  comparison  of  the  diameter 
of  the  ileum  before  operation  and  at  the  post-mortem.  Before 
operation  there  was  undoubtedly,  with  a  chronic  obstruction,  dis- 
tention of  the  ileum.  Did  the  opening  contract  more  in  propor- 
tion than  the  ileum  itself,  and  was  not  the  contraction  of  the  open- 
ing due  to  the  contraction  of  the  ileum  from  its  expanded,  ob- 
structed, preoperative  condition,  to  itsnormal,  contracted, empty  con- 
dition produced  by  a  free  escape  at  the  anastomosis  as  found  in  the 
post-mortem  ?  An  analagous  contraction  to  this  is  shown  in  cases  in 
which  a  cholecystenterostomy  is  performed  experimental!)^;  the 
opening  which  was  original!}'  the  size  of  the  button  used  is  re- 
duced not  by  the  contraction  of  the  cicatrix,  but  by  the  contraction 
of  the  gall  bladder,  which  after  a  number  of  weeks  is  reduced  to 
the  size  of  a  cystic  duct.  Dr.  C.  E.  Ruth,  of  Keokuk,  in  T/ie  0»ia/ia 
C//;//V,  September,  1893,  says:  "I  wish  to  call  especial  attention 
to  the  specimen  in  which  an  approximation  was  made  between  the 
duodenum  and  the  gall  bladder.  You  see  that  what  was  a  gall 
bladder  has  ceased  to  exist  as  such,  and  nothing  remains  of  it  but 
a  duct.      Its  contraction  has  narrowed  the  opening  which  delivered 


45 

a  five-eighth  inch  button  until  it  is  the  size  of  a  slate  pencil  and 
shows  well  marked  folds  of  mucous  membrane  at  its  margins  that 
must  act  as  a  valve  to  prevent  the  passage  of  intestinal  contents 
into  the  gall  bladder." 

A  year  and  four  months  have  elapsed  since  the  first  operation 
of  cholecystenterostomy  with  the  button  was  performed  upon  the 
human  subject,  and  the  symptoms  of  obstructive  jaundice  have 
not  appeared  in  this  nor  any  of  the  subsequent  cases,  as  was  feared 
by  Dr.  Abbe. 

The  following  is  a  report  by  Dr.  J.  Henry  Barbot,  of  San  Fran- 
cisco, of  a  case  in  which  a  post-mortem  was  made:  {Pacific  Med- 
ical Jourtial,  April,  1893).  The  operation  of  gastroenterostomy 
was  performed  on  December  26,  1892.  The  case  was  one  of  car- 
cinoma, involving  a  large  portion  of  the  pyloric  end  of  the 
stomach.  The  button  used  was  made  from  the  description  given 
in  my  paper  in  The  Medical  Record,  December  10,  1892.  The  patient 
gained  ten  pounds  in  three  weeks  after  the  operation.  She- 
became  so  indifferent  about  her  food  that  she  ate  beefsteak,  pota- 
toes, fish,  fried  tripe,  bananas  and  other  food  difficult  of  digestion. 
These  were  all  eaten  before  the  button  was  voided,  and  still  there 
was  no  obstruction.  She  died  February  10,  forty-six  days  after 
operation,  of  an  acute  pulmonary  infection.  The  following  is  the 
doctor's  report  of  post-mortem:  'T  examined  the  stomach  and 
found  the  opening  into  the  bowel  large  enough  to  almost  admit  two 
fingers,  and  the  union  absolutely  perfect."  You  will  note  that  the 
length  of  time  that  had  elapsed  between  the  time  of  operation  and 
death  was  only  one  day  less  than  in  Keen's  case,  still  the  opening 
remained  almost  large  enough  to  admit  two  fingers. 

Dr.  C.  E.  Ruth,  Omaha  Medical  Clinic,  September,  1893,  com- 
ments as  follows:  "This  not  only  simplifies,  but  gives  an  element 
of  certainty  in  this  formerly  impracticable  operation,  that  is 
scarcely  believed  until  seen.  Its  importance  can  scarcely  be  over- 
estimated. The  operation  has  been  done  successful!)'  on  eight 
persons.  You  will  notice  that  no  such  contraction  occurred  in  any 
of  the  specimens  as  that  which  occurred  between  the  gall  bladder 
and  duodenum;  in  fact  none  whatever.  I  have  done  gastroduo- 
denostomy,  cholecystenterostomy,  lateral  and  end  to  end  approx- 
imations, specimens  from  all  of  which  I  now  show  you,  and  in  no 
case  did  I  fail  to  get  firm  union  without  a  fistula  or  a  particle  of 
fecal  or  gaseous  extravasation." 

Dr.  F.  Andrews,  of  Chicago,  in  Omaha  Clinic,  September,  1893, 
says:     "It  is  the  means  par  excellence  for  establishing  a  gastric  or 


46 

fecal  fistula.  B}'  having  a  string  attached,  as  soon  as  pressure 
atrophy  h,as  released  the  button,  it  is  at  once  drawn  out  of  the 
wound,  without  being  allowed  to  pass  through  the  intestinal  tract." 

Dr.  McFadden  Gaston,  referring  to  the  button,  in  Southern 
Medical  Recorder,  ]n\y,  1893,  writes:  "This  device  *  *  *  for  uniting 
different  structures  has  now  been  tested  in  a  sufficient  number  of 
cases  to  afford  a  reasonable  reliance  upon  its  efficacy.  The  results 
were  entirely  satisfactory  in  the  demonstration  of  the  adaptation 
of  the  button  for  anastomosis,  and  there  can  remain  but  little 
doubt  of  a  communication  with  surrounding  adhesion  being  ac- 
complished by  it,  with  more  expedition  than  by  processes  heretofore 
adopted." 

Dr.  Hugh  Ferguson,  Winnepeg,  used  the  button  for  a  case  of 
pylorectomy  with  end  approximation  of  duodenum  to  side  of 
stomach,  also  in  a  case  of  cholecystenterostomy,  both  successful. 
In  a  personal  letter  he  writes  as  follows:  "I  am  more  than  pleased 
with  the  anastomosis  button.  It  is  really  more  than  an  anastomo- 
sis button  and  should  be  designated  'Murphy's  Intestinal  Button.' 
If  a  discussion  on  the  button  arises  at  the  Pan-American  Meeting 
you  may  quote  these  two  cases.  The  button  cannot  be  too  soon 
known." 

Dr.  W.  B.  Rogers,  Memphis,  Tenn.,  July  30,  1893,  writes  :  "I 
would  say  that  immediately  on  my  return  here  I  had  an  opportunity 
for  using  your  button  for  the  operation  of  cholecystenterostomy 
and  it  worked  like  a  charm." 

Dr.  R.  F.  Weir,  of  New  York,  writes:  "I  have  used  the  'button' 
for  cholecystenterostomy  and  like  its  ease  of  application,  though 
the  fatal  ending  prevented  the  fullest  test  being  made.  The  result 
however  was  not  due  to  the  method  but  to  the  case  itself,  which 
was  neoplasm  compressing  common  duct  and  engaging  both  liver 
and  pancreas." 

Dr.  J.  Henry  Barbot,  {Pacific  Medical  Journal,  April,  1893), 
who  used  the  button  in  performing  a  gastroenterostomy,  com- 
ments as  follows:  "An  anastomosis  ma}^  be  done  by  this  method 
with  perfect  safety  and  with  a  result  that  cannot  be  obtained  by 
any  other  method.  The  day  of  bone  plates,  catgut  rings  and  nu- 
merous other  devices,  that  have  been  used  in  performing  the  anas- 
tomosis operations,  is  past  and  every  surgeon  should  provide  him- 
self with  a  set  of  the  buttons  which  does  not  require  an  extensive 
amount  of  operative  skill  to  use." 

In  a  recent  communication  Dr.  Willy  Meyer,  of  New  York, 
favored  me  with  a  report    of    two    successful    operations    with  the 


47 

anastomosis  button  and  commented  as  follows:  "In  both  cases 
your  button  worked  like  a  charm,  impressing  me  and  everybody 
present,  that,  in  your  ingenious  device,  we  have  entered  a  new  era 
of  modern  intestinal  and  gall  bladder  surgery." 

LITERATURE. 

M.  A.  Le  Dentu,  Deux  cas  de  cholecystectomie  pour  lithiase,  un  cas- 
d'ict^re  chronique  cause  par  un  cancer  primitif  du  pancreas,  non  opere.  Bull. 
Acad,  de  Med.  Dec.  30,  '90,  p.  863. 

Rafin.  Phlegmon  de  la  vesiculebiliaire;  incision;  e.Ktraction  decalculs;  gueri- 
son.     Lyon  Medicate,  No.  18,  3  Mai.  1891. 

M.  F.  Terrier.  Cholecystectomie.  Bull,  de  I'Acad.  de  Med.  10  Mars 
1891. 

Thomas  J.  Mays.  Sweet  oil  in  treatment  of  gallstones.  Buffalo  Med.  Jour- 
nal, Nov.  1891,  p.  207. 

James  Bell.  On  a  fatal  case  of  acute  peritonitis.  Montreal  Med.  Journal, 
Vol.  XXI.,  No.  2. 

John  Thomson.  On  congenital  obliteration  of  bile  ducts.  Read  before  Edin- 
burgh Obstet.  Society,  1891. 

D.  N.  Morrison.     Biliary  Calculi.     Maritime  Med.  A^ews,  Sept.  1892,  p.  164. 
S.  R.Morrow.     Discussion  on  treatment  of  gallstones.      Albany  Med.  Annals, 

Vol.  XIII.,  No.  9. 

T.  A.  Pope.  Black  Jaundice.  Courier-Record  of  Medicine,  Texas,  April, 
1892. 

S.  Eastmann.  Clinical  contribution  to  the  surgery  of  the  gall  bladder.  Cin- 
cinnati, Dec,  1891. 

S.  M.  Ward.  Acute  infectious  jaundice.  Aled.  and  Surg.  Reporter,  Vol.  XV., 
p.  490. 

H.  F.  Main.  A  case  of  cholelithiasis.  Australian  Med.  Journal,  Vol.  XII., 
No.  11. 

M.  Terrier.  Ponction  et  resection  de  la  vesicule  biliare.  Bull,  de  I'Acad.  de 
Med.,  Dec.  23,  1890,  p.  831. 

E.  Willemin.  Med.  a  Vichy.  Traitement  de  coliques  hepatiques  par  I'huile 
d'olive. 

Girode.     Quelques  faits  d'ictere  infectieux.      Arch.  Gen.  de.  Med.,  Feb.  1891. 

Terrier.     Archives  Gen.  de  Med.,  February  1891. 

Terrier.  Observations  de  cholecystotomie  et  de  cholecystectomie.  Bull,  de 
I'Acad.  de  Med.,  June  16,  1891. 

Seymour.  Case  of  cholecystotomy.  A/nerican  Med.  Journal,  1892,  Jan.  23, 
p.  95. 

Stein.      Cholecystotomy.      Cincinnati  Lancet-Clinic,    Aug.  15,  1891.  p.  201. 

Mayo  Robson.   Cholecystotomy  for  gallstones.    The  Lancet,  Jan.  10,  1891,  p.  79. 

Reeve.  Some  surgery  of  liver  and  gall  bladder.  N'.  Y.  Med.  Jour?ial,  May 
28,  1892. 

Lange.     Extirpation  of  gall  bladder.     yV.   Y.  Med.  Journal,  Jan  17,  1891. 


48 

Dawson.      Successful  cholecystectomy.     Med.  Ncuis,  Dec.  6,  1890,  p.  597. 

Hamaker.  A  case  of  cholecystotomy.  International  Journal  of  Stirgery^'^z.y, 
1891. 

W.  J.  Mayo.  Report  of  tv\o  operations  for  gallstones.  N'orthtuestern  Lancet, 
April  1892. 

Walker.     Removal  of  gallstones  by  ether  solution.     Lancet,  April,  1891. 

Murphy.     Cholecystotomy.     British  Med.  Journal,  Jan.  24,  1891. 

Easterly  Ashton.  A  case  of  cholecystotomy  for  removal  of  gallstones. 
Therap.  Gazette,  May,  1893. 

Morse.     Cholecystotomy.      Occidental  Med.     Times,     Vol.  V.,  No.  6. 

Perkins.  Case  of  impacted  gallstones  with  abscess  formation.  Kansas  City 
Med.  Index,  Vol.  XII.,  No.  138, 

Seymour.  Personal  experience  with  gallstones  and  operation  for  their  relief. 
Medical  Record,  December  6,  1890. 

Galatz.     Lithisia  biliara.      Clinica,  November  15,  1891. 

Grundzach.  Ueber  Gallensteine  im  Magen.  Wiener  Med.  Presse,  1891,  No.  28. 

Kahler.  Ueber  Cholelithiasis.  Internationale  klifiiscke  Rundschau,  Novem- 
ber 16,  1890. 

Pfuhl.  Zur  Geschichte  der  weilschen  Krankheit.  Berliner  med.  Wochen- 
schrift,  1891,  No.  50,  p.   1,178. 

Rosenberg.  Ueber  die  Methodik  der  Untersuchung  auf  cholagoge  Sub- 
stanzen  und  ueber  deren  Wirkung  bei  katarrhalischem  Icterus  und  der  Gallen- 
steinkrankheit.      Berlin,   klinische  Wochenschrift,  1891,  No.  34,  p.  842. 

Schmitz.  Intermittierende  Fieber  bei  Gallensteinen.  Berlin  klinische  Woch- 
enschrift, 1891,  September. 

Rheinstein.  Die  Palpation  der  Gallenblase.  Berliner  klinische  Wochenschrift, 
December,  1891,  p.  1,211-. 

Sacharyin.  Anwendung  des  Calomel  bei  Erkrankungen  der  Gallenwege.  Ber- 
liner klinische  Wochenschrift,  June  22,  1891. 

Abbe.  A  large  gallstone  producing  complete  intestinal  obstruction.  N.  Y. 
Med.  Journal,  May  2,  1891. 

Syers.     Jaundice  in  children.      The  Lancet,  September  12,  1891. 

Sydney  Jones.  Perforation  of  gall  bladder.  British  Med.  Journal,  April  25, 
1891. 

Seymour.     Treatment  of  gallstones.     Ainer.  Med.  Journal,  April  25,  1891. 

Goodhart.     Remarks  on  gallstones.       British  Med.  Journal,  January  30,  1892. 

Arbuthnot  Lane.      Rupture  of   gall  bladder.      The  Lancet,  May,  1891. 

Wagoner.  Gall  bladder  containing  forty  stones.  N.  Y.  Med.  Journal, 
August,  1891. 

Richardson.  Removal  of  gallstones.  Boston  Medical  and  Surgical  Journal, 
January  to  April,  1892. 

Morton.  Obstruction  and  inflammation  of  gall  bladder.  American  Practi- 
tioner and  Neivs,  Vol.   X.,  No.  12. 

Meachem.  Gallstones  discharged  through  an  abscess.  Med.  Standard, 
August,  1891. 


McCasey.  Cyst  of  peritoneum,  resulting  from  impacted  gallstones.  Kan- 
sas Med.  Journal,  January,  1892. 

Martin.     Cholecystotomy.     British  Med.  Jotirttal,  January,  1893. 

Veer.     Two  cases  of  cholecystotomy.     Medical  Record,  Vol.  40,  No.  22. 

Adams.  A  case  of  biliary  calculus.  Boston  Medical  and  Surgical  Journal, 
Vol.  CXXVI.,  No.  3. 

Macdonald.  A  case  of  cholecystotomy.  Northwestern  Lancet,  July  1.5, 
1891. 

Abbe.     Cases  of    gall   bladder  surgery.     N.   V.  Med.  Journal,  January   1892. 

Marcy.  Surgical  relief  of  biliary  obstruction.  Jnl.  American  Med.  Assn., 
December,  1890. 

Maurice  Richardson.  Gall  bladder  surgery.  Boston  Med.  a7id  Surg.  Jour- 
nal, Vol.  CXXVI.,  No  17. 

Cabot.  Two  cases  of  cholecystotomy.  Boston  Med.  and  Surg.  Journal,  Vol. 
CXXVI.,  No.  17. 

Mixter.  Retention  cyst  of  gall  bladder.  Boston  Med.  and  Surg.  Journal, 
Vol.  CXXVI.,  No.  17. 

Gay.  Cases  of  cholecystotomy.  Boston  Med.  and  Surg.  Journal,  Vol. 
CXXVI.,  No.  17, 

L.  G.  Courvoisier.     Pathologic  und  Chirurgie  der  Gallenwege,  Leipzig,  1890. 

V.  Winiwarter.     Prager  med.  Wochenschrift,  1892,  No.  21,  22. 

Kappeler.     Corrbl.  fur  Schweizer  Aerzte,  1887,  No.  17  and  1889,  No.  4. 

Dastre.      Corrbl.  fur .  Schweizer  Aerzte,  1889,    No.  20. 

Monastyrski.  Chirurg.  Westtiick,  1888,  May  and  June  refer.  Ctrbl.  fur  Chir. 
1888. 

-  Socin  F.     Ber.  d.  chir.  Abthl.  d.  Easier  Spitals,  1887,  pp.  60,  61. 

Fritsche  und  Blattmann.      Corrbl.  f.  Schweizer  Aerzte,  No.  6,  1890. 

Mayo  Robson.     Brit.  Med.  Jotirnal,  Nov.,  1889. 

Terrier.     Revue  de.  Chirurg.  1889,  No.  12. 

Bardenheuer.  Tageblatt  d.  6i  Vsmmlg.  Deutscher  Nattirforscher  und  Aerzte,  in 
Koln;  Berlin,  klin.  Wochenschrift,  1888,  October  22  and  Centralbl.  fur  Chir.,  1889, 
No.  12. 

Czerny.     Deutchemed.   Wochenschrift,  1892,  No.  23,  p.  516. 

Lambotte.     La  Presse  Medicate  Beige,  July  3,  1892. 

Connell.     New  York  Med.  Record,  September,  1892. 

Herbert  Page.  Proceedings  of  the  Royal  Med.  and  Chir.  Society  of  London. 
Brit.   Med.  Journal,  May  18,  1889. 

Von  Hacker,  Jahrbiich  der  K.  K.  Gesellschaft  der  Aerzte  in  Wien,  1890. 

Roman  Von  Baracz.    Langenbecks  Archiv.  fur  klinische  Chirurgie,  Sept.,  1892, 

Landois  and  Sterling.     Physiologie,  1890. 


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